MEDICARE: MARY BLACK HEALTH SYSTEM, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	363A00000X	Physician Assistant
3	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922013721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY BLACK HEALTH SYSTEM, LLC

Provider Business Mailing Address
First Line	:	PO BOX 406757
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-6757
Country	:	US
Telephone Number	:	864-253-8063
Fax Number	:

Provider Business Practice Location Address
First Line	:	2212 OLD FURNACE RD
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-5782
Country	:	US
Telephone Number	:	864-578-9735
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	REBECCA HURLEY
Credential	:
Telephone Number	:	214-473-3993

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	06/25/2008

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Directions to “MARY BLACK HEALTH SYSTEM, LLC ” Practice Location

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