Organization
MARY BLACK PHYSICIANS GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DONNA L MATTSON (SENIOR CREDENTIALING COORDINATOR)
(214) 473-7043
Entity
Organization
Contact information
Practice address
170 CAMELOT DR, SPARTANBURG, SC 29301-2650
(864) 576-1614
Mailing address
PO BOX 277827, ATLANTA, GA 30384-7827
(864) 576-1614
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Enumeration date
04/24/2007
Last updated
06/12/2009
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