Healthcare Provider Details

I. General information

NPI: 1134364615
Provider Name (Legal Business Name): MARY BLACK PHYSICIANS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5229 HIGHWAY 221
ROEBUCK SC
29376-3305
US

IV. Provider business mailing address

PO BOX 277827
ATLANTA GA
30384-7827
US

V. Phone/Fax

Practice location:
  • Phone: 864-576-8193
  • Fax:
Mailing address:
  • Phone: 864-253-8063
  • Fax: 864-582-5188

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 PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626