1326067703 NPI number — SELF REGIONAL HEALTHCARE

Table of content: (NPI 1326067703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326067703 NPI number — SELF REGIONAL HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELF REGIONAL HEALTHCARE
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:
MONTGOMERY CENTER FOR FAMILY MEDICINE OF SRH
Provider Other Organization Name Type Code:
3
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:
1326067703
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:
155 ACADEMY AVE
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:
29646-3808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-725-4865
Provider Business Mailing Address Fax Number:
864-725-4883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 ACADEMY AVE
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:
29646-3869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-725-4865
Provider Business Practice Location Address Fax Number:
864-725-4883
Provider Enumeration Date:
07/18/2006

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 & CEO
Authorized Official Telephone Number:
864-725-4253

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  038 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CE6182 . This is a "MEDICARE RR GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: PC3251 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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