Healthcare Provider Details

I. General information

NPI: 1326061540
Provider Name (Legal Business Name): MARY BLACK HEALTH SYSTEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5470 N MAIN ST
COWPENS SC
29330-9705
US

IV. Provider business mailing address

PO BOX 406757
ATLANTA GA
30384-6757
US

V. Phone/Fax

Practice location:
  • Phone: 864-463-3286
  • Fax:
Mailing address:
  • Phone: 864-253-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7000