1073620654 NPI number — MARY BLACK HEALTH SYSTEM LLC

Table of content: (NPI 1073620654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073620654 NPI number — MARY BLACK HEALTH SYSTEM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY BLACK HEALTH SYSTEM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073620654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 DILLON DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29307-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-542-8980
Provider Business Mailing Address Fax Number:
864-515-9994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1686 SKYLYN DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29307-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-573-3272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-7000

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP2893 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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