NPIMap

Organization Active NPI

Mary Black Physician Services LLC

  • Nurse Practitioner
  • Duncan, SC
National Provider Identifier
1811950645
Registry record updated Jun 20, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
MARY BLACK PHYSICIAN SERVICES LLC
Practice address
170 Ridgeview Center Dr
Duncan, SC 29334-9635
Phone
(864) 573-3124
Fax
(864) 582-5188
NPI assigned
Apr 11, 2006
Last updated
Jun 20, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 20, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tammy V McCollum
Title
Business Office Director
Phone
(864) 253-8063

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopaedic Surgery Physician 207X00000X
Physician Assistant 363A00000X SC
Nurse Practitioner 363L00000X SC Primary

Addresses

Primary practice location

170 Ridgeview Center Dr
Duncan, SC 29334-9635

Mailing address

145B Dillon Dr
Spartanburg, SC 29307-1017
Phone (865) 253-8063

Other practice location 1

724 Hyatt St
Ste. F
Gaffney, SC 29341-2630
Phone (864) 488-2507

Other identifiers 5

IdentifierTypeStateIssuer
GP4319MedicaidSC
GP4169MedicaidSC
GP4353MedicaidSC
800572901OtherTAX ID
GP4168MedicaidSC

National Provider Directory

National Provider Directory

Locations

170 Ridgeview Center Dr
Duncan, SC 29334
Phone (864) 573-3124

1690 Skylyn Dr
Ste 130
Spartanburg, SC 29307
Phone (864) 585-2207

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 36

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 36

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144713600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1529452800000",
    "number": "1811950645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "145B DILLON DR",
            "city": "SPARTANBURG",
            "state": "SC",
            "postal_code": "293071017",
            "telephone_number": "865-253-8063",
            "fax_number": "864-582-5188"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "170 RIDGEVIEW CENTER DR",
            "city": "DUNCAN",
            "state": "SC",
            "postal_code": "293349635",
            "telephone_number": "864-573-3124",
            "fax_number": "864-582-5188"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "724 Hyatt St",
            "address_2": "Ste. F",
            "address_purpose": "LOCATION",
            "city": "Gaffney",
            "state": "SC",
            "postal_code": "293412630",
            "country_code": "US",
            "telephone_number": "864-488-2507",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MARY BLACK PHYSICIAN SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-11",
        "last_updated": "2018-06-20",
        "status": "A",
        "authorized_official_last_name": "MCCOLLUM",
        "authorized_official_first_name": "TAMMY",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "BUSINESS OFFICE DIRECTOR",
        "authorized_official_telephone_number": "864-253-8063"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "SC",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP4319",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP4169",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP4353",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAX ID",
            "identifier": "800572901",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP4168",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Duncan, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.