Provider Demographics
NPI:1598983330
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:VP
Authorized Official - Prefix:
Authorized Official - First Name:V
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:FLINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3773
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:864-488-1400
Mailing Address - Fax:
Practice Address - Street 1:722 HYATT ST
Practice Address - Street 2:SUITE B
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2643
Practice Address - Country:US
Practice Address - Phone:864-488-1400
Practice Address - Fax:864-488-1057
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:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5878670009Medicare NSC