Provider Demographics
NPI:1568655587
Name:MARY BLACK PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:MARY BLACK PHYSICIAN SERVICES, LLC
Other - Org Name:STEADMAN HAWKINS CLINIC OF THE CAROLINAS
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 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 SKYLYN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1047
Practice Address - Country:US
Practice Address - Phone:864-216-4640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK PHYSICIANS SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-22
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
SC5474940002Medicare NSC