Provider Demographics
NPI:1699975300
Name:MARY BLACK PHYSICIANS GROUP, LLC
Entity type:Organization
Organization Name:MARY BLACK PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:V
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:FLINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3773
Mailing Address - Street 1:PO BOX 277827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7827
Mailing Address - Country:US
Mailing Address - Phone:864-253-8080
Mailing Address - Fax:
Practice Address - Street 1:724 HYATT ST
Practice Address - Street 2:STE #F
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2630
Practice Address - Country:US
Practice Address - Phone:864-489-5001
Practice Address - Fax:864-489-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGP4690Medicaid
SC8688Medicare PIN