1962584938 NPI number — MARY BLACK PHYSICIANS GROUP LLC

Table of content: (NPI 1962584938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962584938 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:
1962584938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 THOMPSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29379-7409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-427-9311
Provider Business Mailing Address Fax Number:
864-427-9309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 THOMPSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29379-7409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-427-9311
Provider Business Practice Location Address Fax Number:
864-427-9309
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
877-892-9813

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com