1134137581 NPI number — MARY BLACK HEALTH SYSTEM, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134137581 NPI number — MARY BLACK HEALTH SYSTEM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY BLACK HEALTH SYSTEM, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HILLCREST FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134137581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 DILLON DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29307-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-542-8980
Provider Business Mailing Address Fax Number:
864-515-9994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1770 SKYLYN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29307-1045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-582-7200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-7000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP1605 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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