Provider Demographics
NPI:1295819415
Name:MARY BLACK PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:V
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:FLINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3773
Mailing Address - Street 1:500 SQUIRE'S POINTE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-8867
Mailing Address - Country:US
Mailing Address - Phone:864-433-8980
Mailing Address - Fax:864-433-8982
Practice Address - Street 1:500 SQUIRE'S POINTE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-8867
Practice Address - Country:US
Practice Address - Phone:864-433-8980
Practice Address - Fax:864-433-8982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherTIN