Provider Demographics
NPI:1932117389
Name:MARY BLACK HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM, LLC
Other - Org Name:FOOTHILLS FAMILY MEDICINE EAST BLACKSTOCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE PARELEGAL
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: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:864-253-8063
Mailing Address - Fax:
Practice Address - Street 1:245 E BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2633
Practice Address - Country:US
Practice Address - Phone:864-576-1614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK HEALTH SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1612Medicaid
SC5300Medicare PIN