Provider Demographics
NPI:1982612925
Name:MARY BLACK HEALTH SYSTEM LLC
Entity type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMETN
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:PO BOX 406757
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-6757
Mailing Address - Country:US
Mailing Address - Phone:864-253-8080
Mailing Address - Fax:
Practice Address - Street 1:2995 REIDVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5600
Practice Address - Country:US
Practice Address - Phone:864-587-3000
Practice Address - Fax:864-587-3019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK HEALTH SYSTEM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-04
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4384Medicaid
SC5286Medicare PIN