Provider Demographics
NPI:1992758296
Name:MARY BLACK HEALTH SYSTEM LLC
Entity type:Organization
Organization Name:MARY BLACK HEALTH SYSTEM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-925-4565
Mailing Address - Street 1:1700 SKYLYN DR
Mailing Address - Street 2:PO BOX 3217
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304
Mailing Address - Country:US
Mailing Address - Phone:864-573-3000
Mailing Address - Fax:864-573-3277
Practice Address - Street 1:1700 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1041
Practice Address - Country:US
Practice Address - Phone:864-573-3000
Practice Address - Fax:864-573-3277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY BLACK HEALTH SYSTEM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-704273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400836Medicaid
SC382184Medicaid
SC400836Medicaid