Healthcare Provider Details

I. General information

NPI: 1609983287
Provider Name (Legal Business Name): MARY BLACK HEALTH SYSTEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 HYATT ST STE 2-D
GAFFNEY SC
29341-2630
US

IV. Provider business mailing address

138 DILLON DR STE A
SPARTANBURG SC
29307-1018
US

V. Phone/Fax

Practice location:
  • Phone: 864-489-5001
  • Fax:
Mailing address:
  • Phone: 864-542-8980
  • Fax: 864-515-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

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