Evan George Black, M.D.

Primary specialty

Neurology PhysicianTaxonomy code 2084N0400X

License

MD205738 Issued in OR

Practice address

5323 Woodrow St
#201
Murray, UT 84107-5841

Phone

(801) 261-4711

Fax

(801) 261-4769

NPI assigned

Jul 20, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 6

Addresses

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in UT, WI, MI, GA, OR, SD6 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 6

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: eblackmd384015@direct.froedtert.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Columbus Ambulatory Healthcare Services, Inc.

  • Family Medicine Physician
  • Columbus, GA
  • NPI 1790733244

  Single Specialty

  Medicare reassignment NPD
• Froedtert &the Medical College of Wisconsin Community Physicians, Inc.

  • Internal Medicine Physician
  • Menomonee Falls, WI
  • NPI 1568787448

  Single Specialty

  Medicare reassignment NPD
• Lakeland Medical Practices

  dba Corewell Health Medical Group South

  • Internal Medicine Physician
  • Saint Joseph, MI
  • NPI 1538397120

  Single Specialty

  Medicare reassignment NPD
• Legacy Clinics LLC

  • Clinic/Center
  • Portland, OR
  • NPI 1902827272

  Single Specialty

  Medicare reassignment NPD
• Piedmont Athens Hospitalist Physicians LLC

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1578079000

  Single Specialty

  Medicare reassignment NPD
• Upson County Hospital Inc

  dba Upson Regional Medical Center

  • General Acute Care Hospital
  • Thomaston, GA
  • NPI 1659376630

  Single Specialty

  Medicare reassignment NPD
• St Mark's Professional Services, LLC

  • Internal Medicine Physician
  • Salt Lake City, UT
  • NPI 1912925629
  Medicare reassignment
• Access Telecare, PLLC

  • Internal Medicine Physician
  • Dallas, TX
  • NPI 1013303080

  Single Specialty

  NPD
• Columbus Ambulatory Healthcare Services, Inc.

  • Family Medicine Physician
  • Phenix City, AL
  • NPI 1699240531

  Single Specialty

  NPD
• Froedtert &the Medical College of Wisconsin Community Physicians, Inc.

  • Durable Medical Equipment & Medical Supplies
  • Wauwatosa, WI
  • NPI 1154947224

  Single Specialty

  NPD
• Lakeland Medical Practices

  dba Corewell Health Medical Group South

  • Internal Medicine Physician
  • Bridgman, MI
  • NPI 1568232247
  NPD
• Legacy Clinics LLC

  dba Legacy Medical Group Firwood

  • Rural Health Clinic/Center
  • Sandy, OR
  • NPI 1730472192
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1672704000000",
    "number": "1346260247",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5323 WOODROW ST",
            "address_2": "#201",
            "city": "MURRAY",
            "state": "UT",
            "postal_code": "841075841",
            "telephone_number": "801-261-4711",
            "fax_number": "801-261-4769"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5323 WOODROW ST",
            "address_2": "#201",
            "city": "MURRAY",
            "state": "UT",
            "postal_code": "841075841",
            "telephone_number": "801-261-4711",
            "fax_number": "801-261-4769"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "630 Eaton Ave",
            "address_purpose": "LOCATION",
            "city": "Hamilton",
            "state": "OH",
            "postal_code": "450132767",
            "country_code": "US",
            "telephone_number": "513-867-2000",
            "fax_number": "513-867-2119",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1250 S Cedar Crest Blvd Ste 405",
            "address_purpose": "LOCATION",
            "city": "Allentown",
            "state": "PA",
            "postal_code": "181036224",
            "country_code": "US",
            "telephone_number": "610-402-8420",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "11215 Metro Pkwy Ste 1",
            "address_purpose": "LOCATION",
            "city": "Fort Myers",
            "state": "FL",
            "postal_code": "339661206",
            "country_code": "US",
            "telephone_number": "239-208-2212",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLACK",
        "first_name": "EVAN",
        "middle_name": "GEORGE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-07-20",
        "last_updated": "2023-01-03",
        "certification_date": "2023-01-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "PA",
            "license": "MD476184",
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "UT",
            "license": "187597-1205",
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "NH",
            "license": "21619",
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "MT",
            "license": "99622",
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "GA",
            "license": "89191",
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "OR",
            "license": "MD205738",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "eblack778853@direct.ketteringhealth.org",
            "affiliation": "N",
            "address_1": "630 Eaton Ave",
            "city": "Hamilton",
            "state": "OH",
            "country_code": "US",
            "postal_code": "450132767",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https:/khnarr.ketthealth.com/FHIR-PROD/api/FHIR/R4/",
            "affiliation": "N",
            "address_1": "630 Eaton Ave",
            "city": "Hamilton",
            "state": "OH",
            "country_code": "US",
            "postal_code": "450132767",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Angela Sue Bishop, FNP-C
• Brandon Bissell
• Brittany Kay Bitters, LCSW
• Kendal Lena Bjella, RDN
• Atlanta Black
• Maureen Black, RN
• Benjamin W Blackburn, PA-C
• Charlene Blackburn, MOTR/L
• Jennifer Blackburn, LCSW
• Brenda K Blackham, MD

• Neurology Physician in Murray, UT
• Providers in Murray, UT by specialty
• Neurology Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.