Healthcare Provider Details

I. General information

NPI: 1770701534
Provider Name (Legal Business Name): MARY BLACK PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 DILLON DR
SPARTANBURG SC
29307-1017
US

IV. Provider business mailing address

PO BOX 277827
ATLANTA GA
30384-7827
US

V. Phone/Fax

Practice location:
  • Phone: 864-458-5806
  • Fax: 864-585-8322
Mailing address:
  • Phone: 864-253-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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