| Organization Name: | MARY BLACK PHYSICIANS GROUP, LLC |
| NPI Number: | 1952546434 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DEBBIE BREWER (DIRECTOR PROVIDER ENROLLMENT) |
| Mailing Address: | 108 W Rutherford St Landrum |
| State: | SC US |
| Postal Code: | 293561526 |
| Phone Number: | 8644572363 |
| Fax Number: | |
| NPI Enumeration Date: | 12/11/2008 |
| NPI Last Update Date: | 12/11/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |