Provider Demographics
NPI:1053556191
Name:MARY BLACK PHYSICIANS GROUP LLC
Entity type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:2995 REIDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5628
Mailing Address - Country:US
Mailing Address - Phone:864-587-3000
Mailing Address - Fax:
Practice Address - Street 1:2995 REIDVILLE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5628
Practice Address - Country:US
Practice Address - Phone:864-587-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK PHYSICIANS GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-03
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5878670026Medicare NSC