Provider Demographics
NPI:1629090568
Name:MARY BLACK HEALTH SYSTEM LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM LLC
Other - Org Name:FOOTHILLS FAMILY MEDICINE
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 1:391 GLENN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PACOLET
Mailing Address - State:SC
Mailing Address - Zip Code:29372-2417
Mailing Address - Country:US
Mailing Address - Phone:864-474-3013
Mailing Address - Fax:
Practice Address - Street 1:391 GLENN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PACOLET
Practice Address - State:SC
Practice Address - Zip Code:29372-2417
Practice Address - Country:US
Practice Address - Phone:864-474-3013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK HEALTH SYSTEM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-23
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1607Medicaid
SCGP1607Medicaid