Healthcare Provider Details

I. General information

NPI: 1982612925
Provider Name (Legal Business Name): MARY BLACK HEALTH SYSTEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2995 REIDVILLE RD STE 100
SPARTANBURG SC
29301-5600
US

IV. Provider business mailing address

PO BOX 406757
ATLANTA GA
30384-6757
US

V. Phone/Fax

Practice location:
  • Phone: 864-587-3000
  • Fax: 864-587-3019
Mailing address:
  • Phone: 864-253-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMETN
Credential:
Phone: 615-465-7626