Provider Demographics
NPI:1740425305
Name:MARY BLACK PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP, LLC
Other - Org Name:FAMILY PRACTICE ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR 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:615-465-7626
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:864-253-8080
Mailing Address - Fax:864-582-5188
Practice Address - Street 1:429 E MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-1902
Practice Address - Country:US
Practice Address - Phone:864-427-9045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK PHYSICIANS GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4766Medicaid
SCGP4766Medicaid