Provider Demographics
NPI:1588809198
Name:MARY BLACK PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP, LLC
Other - Org Name:PIEDMONT RHEUMATOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR 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:615-465-7626
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:864-582-5188
Practice Address - Street 1:1770 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1045
Practice Address - Country:US
Practice Address - Phone:864-582-7892
Practice Address - Fax:864-582-1269
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK PHYSICIANS GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4763Medicaid
SCGP4763Medicaid