Provider Demographics
NPI:1336344852
Name:MARY BLACK PHYSICIANS GROUP LLC
Entity Type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP LLC
Other - Org Name:MARY BLACK FAMILY MEDICINE DORMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:5229 HIGHWAY 221
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-3305
Mailing Address - Country:US
Mailing Address - Phone:864-576-8193
Mailing Address - Fax:
Practice Address - Street 1:5229 HIGHWAY 221
Practice Address - Street 2:
Practice Address - City:ROEBUCK
Practice Address - State:SC
Practice Address - Zip Code:29376-3305
Practice Address - Country:US
Practice Address - Phone:864-576-8193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK PHYSICIANS GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-15
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC428993Medicare Oscar/Certification