Provider Demographics
NPI:1619990884
Name:SELF REGIONAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SELF REGIONAL PHYSICIAN SERVICES
Other - Org Name:THE FAMILY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PFEIFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-725-4253
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325
Mailing Address - Country:US
Mailing Address - Phone:864-833-5986
Mailing Address - Fax:864-833-0599
Practice Address - Street 1:22580 HIGHWAY 76 E
Practice Address - Street 2:SUITE 100
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-8439
Practice Address - Country:US
Practice Address - Phone:864-833-5986
Practice Address - Fax:864-833-0599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELF REGIONAL PHYSICIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4470Medicaid
0572110001Medicare NSC
SCGP4470Medicaid
SC8536Medicare PIN