Provider Demographics
NPI:1972721728
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:VP
Authorized Official - Prefix:
Authorized Official - First Name:V
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:FLINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3773
Mailing Address - Street 1:702 S ALABAMA AVE
Mailing Address - Street 2:PO BOX 558
Mailing Address - City:CHESNEE
Mailing Address - State:SC
Mailing Address - Zip Code:29323-1706
Mailing Address - Country:US
Mailing Address - Phone:864-703-1419
Mailing Address - Fax:
Practice Address - Street 1:702 S ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:CHESNEE
Practice Address - State:SC
Practice Address - Zip Code:29323-1706
Practice Address - Country:US
Practice Address - Phone:864-703-1419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5872670021Medicare NSC
SC8688Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER