Provider Demographics
NPI:1710995105
Name:MARY BLACK HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM, LLC
Other - Org Name:KIESAU GYNECOLOGY ASSOCIATES
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:214-473-3993
Mailing Address - Street 1:138 DILLON DR STE A
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1018
Mailing Address - Country:US
Mailing Address - Phone:864-542-8980
Mailing Address - Fax:864-515-9994
Practice Address - Street 1:123 DILLON DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1017
Practice Address - Country:US
Practice Address - Phone:864-585-8064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3445Medicaid
SCGP3445Medicaid
5286Medicare ID - Type Unspecified