1134442890 NPI number — SELF MEDICAL GROUP

Table of content: (NPI 1134442890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134442890 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:
Provider Other Organization Name Type Code:
6
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:
1134442890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/22/2012
NPI Reactivation Date:
09/11/2013

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 ACADEMY AVENUE
Provider Second Line Business Mailing Address:
UNIT A
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-725-7272
Provider Business Mailing Address Fax Number:
864-725-5764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 ACADEMY AVENUE
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-725-7272
Provider Business Practice Location Address Fax Number:
864-725-5764
Provider Enumeration Date:
03/10/2010

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 CEO
Authorized Official Telephone Number:
864-725-4253

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP5374 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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