Provider Demographics
NPI:1376761155
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:SENIOR CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-7043
Mailing Address - Street 1:148 DILLON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1018
Mailing Address - Country:US
Mailing Address - Phone:864-582-1089
Mailing Address - Fax:
Practice Address - Street 1:148 DILLON DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1018
Practice Address - Country:US
Practice Address - Phone:864-582-1089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK PHYSICIANS GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-24
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5878670016Medicare NSC