Organization
MARY BLACK PHYSICIAN SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TAMMY V MCCOLLUM (BUSINESS OFFICE DIRECTOR)
(864) 253-8063
Entity
Organization
Contact information
Practice address
170 RIDGEVIEW CENTER DR, DUNCAN, SC 29334-9635
(864) 573-3124
(864) 582-5188
Mailing address
145B DILLON DR, SPARTANBURG, SC 29307-1017
(865) 253-8063
(864) 582-5188
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
—
—
363A00000X
Physician Assistant
—
SC
363L00000X
Nurse Practitioner
Primary
—
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
800572901
TAX ID
—
05
—
GP4168
—
SC
05
—
GP4169
—
SC
05
—
GP4319
—
SC
05
—
GP4353
—
SC
Enumeration date
04/11/2006
Last updated
06/20/2018
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