Provider Demographics
NPI:1588679922
Name:MARY BLACK HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM, LLC
Other - Org Name:PEDIATRIC ASSOCIATES
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 1:138 DILLON DR STE A
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:864-542-8980
Mailing Address - Fax:864-515-9994
Practice Address - Street 1:147 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1207
Practice Address - Country:US
Practice Address - Phone:864-582-8135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK HEALTH SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2480Medicaid
5286Medicare ID - Type Unspecified