1174842090 NPI number — SELF MEDICAL GROUP

Table of content: (NPI 1174842090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174842090 NPI number — SELF MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELF MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVANCED ONCOLOGY HEMATOLOGY, A DIVISION OF SELF MEDICAL GROUP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174842090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 SPRING STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29646-3860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-725-7100
Provider Business Mailing Address Fax Number:
864-725-7101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 SPRING STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29646-3860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-725-7100
Provider Business Practice Location Address Fax Number:
864-725-7101
Provider Enumeration Date:
05/18/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOGAN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT AND CHIEF EXECUTIVE OFFIC
Authorized Official Telephone Number:
864-725-4253

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)