MEDICARE: MARY BLACK PHYSICIANS GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1316164551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY BLACK PHYSICIANS GROUP LLC

Provider Business Mailing Address
First Line	:	2212 OLD FURNACE RD
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-5782
Country	:	US
Telephone Number	:	864-578-9735
Fax Number	:	864-578-7098

Provider Business Practice Location Address
First Line	:	2212 OLD FURNACE RD
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-5782
Country	:	US
Telephone Number	:	864-578-9735
Fax Number	:	864-578-7098

Authorized Official
Title or Position	:	VP
Name	:	V KAREN FLINN
Credential	:
Telephone Number	:	214-473-3773

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	06/12/2009

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