MEDICARE: MARY BLACK PHYSICIANS GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1902988983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY BLACK PHYSICIANS GROUP, LLC

Provider Business Mailing Address
First Line	:	391 GLENN SPRINGS RD
Second Line	:
City	:	PACOLET
State	:	SC
Zip	:	29372-2417
Country	:	US
Telephone Number	:	864-703-1414
Fax Number	:	864-703-1419

Provider Business Practice Location Address
First Line	:	391 GLENN SPRINGS RD
Second Line	:
City	:	PACOLET
State	:	SC
Zip	:	29372-2417
Country	:	US
Telephone Number	:	864-703-1414
Fax Number	:	864-703-1419

Authorized Official
Title or Position	:	VP
Name	:	V KAREN FLINN
Credential	:
Telephone Number	:	214-473-3773

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	08/22/2020

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