Provider Demographics
NPI:1093171332
Name:MARY BLACK PHYSICIANS GROUP LLC
Entity Type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP LLC
Other - Org Name:ORTHO UPSTATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-778-8076
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-778-8540
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:722 HYATT ST
Practice Address - Street 2:SUITE D
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2643
Practice Address - Country:US
Practice Address - Phone:864-488-3336
Practice Address - Fax:864-488-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies