Provider Demographics
NPI:1518187228
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:PO BOX 277827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7827
Mailing Address - Country:US
Mailing Address - Phone:864-253-8080
Mailing Address - Fax:
Practice Address - Street 1:500 SQUIRES PT
Practice Address - Street 2:SUITE B
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8688Medicare ID - Type Unspecified
SC5878670004Medicare PIN