Individual
SUMMER R BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
(618) 529-0449
Mailing address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
(618) 529-0449
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209021758
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
214881
GROUP PTAN
IL
Enumeration date
04/22/2020
Last updated
11/09/2020
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