1205071784 NPI number — MARY BLACK PHYSICIANS GROUP, LLC

Table of content: (NPI 1205071784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205071784 NPI number — MARY BLACK PHYSICIANS GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY BLACK PHYSICIANS GROUP, 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:
Provider Other Organization Name Type Code:
6
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:
1205071784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 277827
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-7827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-253-8063
Provider Business Mailing Address Fax Number:
864-582-5188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1686 SKYLYN DR STE 201
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:
29307-1079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-582-8135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-7626

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP4779 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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