Provider Demographics
NPI:1992990501
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 OF PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:724 HYATT ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29341-2630
Mailing Address - Country:US
Mailing Address - Phone:864-489-5001
Mailing Address - Fax:864-488-3958
Practice Address - Street 1:724 HYATT ST
Practice Address - Street 2:SUITE D
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:864-488-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0456110022OtherMEDICARE DME PIN