1104137892 NPI number — SELF MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104137892 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:
1104137892
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:
22580 HIGHWAY 76 E
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAURENS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29360-8439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-833-0055
Provider Business Mailing Address Fax Number:
864-833-4008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22580 HIGHWAY 76 E
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAURENS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29360-8439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-833-0055
Provider Business Practice Location Address Fax Number:
864-833-4008
Provider Enumeration Date:
06/28/2010

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: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP5453 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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