Basic Information
| Provider Information | |||||||||
| NPI: | 1619339660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY BLACK PHYSICIANS GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTSIDE MINOR CAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157788540 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 2995 REIDVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293015628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645873000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2016 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | SWAW | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6157788076 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.