Provider Demographics
NPI:1669672358
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:DIRECTOR
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:877-892-9813
Mailing Address - Street 1:5470 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COWPENS
Mailing Address - State:SC
Mailing Address - Zip Code:29330-9705
Mailing Address - Country:US
Mailing Address - Phone:864-463-3286
Mailing Address - Fax:864-463-3286
Practice Address - Street 1:5470 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COWPENS
Practice Address - State:SC
Practice Address - Zip Code:29330-9705
Practice Address - Country:US
Practice Address - Phone:864-463-3286
Practice Address - Fax:864-463-3286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI8688Medicare PIN
SC5878670022Medicare NSC