Provider Demographics
NPI:1699839530
Name:MARY BLACK HEALTH SYSTEM LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM LLC
Other - Org Name:CAROLINA ORTHOPAEDIC SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-488-2507
Mailing Address - Street 1:PO BOX 406757
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-6757
Mailing Address - Country:US
Mailing Address - Phone:864-488-2507
Mailing Address - Fax:864-488-9031
Practice Address - Street 1:724 HYATT ST
Practice Address - Street 2:SUITE F
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2630
Practice Address - Country:US
Practice Address - Phone:864-488-2507
Practice Address - Fax:864-488-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3681Medicaid
7592Medicare ID - Type Unspecified
5286Medicare ID - Type Unspecified