Provider Demographics
NPI:1083640981
Name:MARY BLACK HEALTH SYSTEM LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM LLC
Other - Org Name:MARY BLACK MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3993
Mailing Address - Street 1:1700 SKYLYN DR
Mailing Address - Street 2:PO BOX 3217
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1041
Mailing Address - Country:US
Mailing Address - Phone:864-573-3000
Mailing Address - Fax:864-573-3277
Practice Address - Street 1:1700 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1041
Practice Address - Country:US
Practice Address - Phone:864-573-3000
Practice Address - Fax:864-573-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-704207RC0000X, 207RC0001X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Not Answered208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1764Medicaid
5284Medicare ID - Type UnspecifiedHOSPITAL PART B PRO FEE