Active NPI
Robert Grant Black, PT
- Physical Therapist
- Pocatello, ID
National Provider Identifier
1457499428
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 3435682401
- Practice address
- 285 Vista Drive
Suite a
Pocatello, ID 83201 - Phone
- (208) 478-1488
- Fax
- (208) 478-1498
- NPI assigned
- Feb 2, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 3435682401 | UT | Primary |
| Specialist | 174400000X | PT-1705 | ID |
Addresses
Primary practice location
285 Vista Drive
Suite a
Pocatello, ID 83201
Mailing address
2176 E. Franklin Road
Suite 100
Meridian, ID 83642-9024
Phone (208) 288-1155
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| D4888 | Medicaid | UT |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in UT
Enrollment records 1
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT-1705 | ID | MD | Specialist |
| 3435682401 | UT | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Rehabauthority, LLC | Physical Therapist | Past | Accepting new patients |
| Lake Area Physical Therapy | Physical Therapist | Past | Accepting new patients |
Organizations & group practices 3
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.
-
- Physical Therapist
- Kaysville, UT
- NPI 1558511451
-
- Physical Therapist
- Keystone Heights, FL
- NPI 1316212475
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170374400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1219190400000",
"number": "1457499428",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2176 E. FRANKLIN ROAD",
"address_2": "SUITE 100",
"city": "MERIDIAN",
"state": "ID",
"postal_code": "836429024",
"telephone_number": "208-288-1155",
"fax_number": "208-288-0424"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "285 VISTA DRIVE",
"address_2": "SUITE A",
"city": "POCATELLO",
"state": "ID",
"postal_code": "83201",
"telephone_number": "208-478-1488",
"fax_number": "208-478-1498"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BLACK",
"first_name": "ROBERT",
"middle_name": "GRANT",
"credential": "PT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-02-02",
"last_updated": "2008-08-20",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "UT",
"license": "3435682401",
"primary": true
},
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "ID",
"license": "PT-1705",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "D4888",
"state": "UT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Pocatello, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.