Basic Information
| Provider Information | |||||||||
| NPI: | 1639254683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY BLACK PHYSICIANS GROUP LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY PRACTICE ASSOCIATES PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 429 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293791902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644279045 | ||||||||
| FaxNumber: | 8644278826 | ||||||||
| Practice Location | |||||||||
| Address1: | 429 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293791902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644279045 | ||||||||
| FaxNumber: | 8644278826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8778929813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARY BLACK PHYSICIANS GROUP LLC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.