Healthcare Provider Details

I. General information

NPI: 1336344852
Provider Name (Legal Business Name): MARY BLACK PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5229 HIGHWAY 221
ROEBUCK SC
29376-3305
US

IV. Provider business mailing address

5229 HIGHWAY 221
ROEBUCK SC
29376-3305
US

V. Phone/Fax

Practice location:
  • Phone: 864-576-8193
  • Fax:
Mailing address:
  • Phone: 864-576-8193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR
Credential:
Phone: 877-892-9813