Healthcare Provider Details

I. General information

NPI: 1073620654
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

1686 SKYLYN DR STE 102
SPARTANBURG SC
29307-1058
US

IV. Provider business mailing address

138 DILLON DR STE A
SPARTANBURG SC
29307-1018
US

V. Phone/Fax

Practice location:
  • Phone: 864-573-3272
  • Fax:
Mailing address:
  • Phone: 864-542-8980
  • Fax: 864-515-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal 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