Provider Demographics
NPI:1326061540
Name:MARY BLACK HEALTH SYSTEM LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM LLC
Other - Org Name:FOOTHILLS FAMILY MEDICINE COWPENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
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:615-465-7000
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 1:5470 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COWPENS
Practice Address - State:SC
Practice Address - Zip Code:29330-9705
Practice Address - Country:US
Practice Address - Phone:864-463-3286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK HEALTH SYSTEM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1603Medicaid
SCGP1603Medicaid