MEDICARE: SELF INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	807186	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164574026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF INC.

Provider Business Mailing Address
First Line	:	1425 ARCH ST
Second Line	:	SUITE 300
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1507
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 ARCH ST
Second Line	:	SUITE 300
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1507
Country	:	US
Telephone Number	:	215-496-9610
Fax Number	:

Authorized Official
Title or Position	:	CPO
Name	:	MR. NATHANIEL ROBINSON
Credential	:
Telephone Number	:	215-496-9610

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	08/08/2007

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Directions to “SELF INC. ” Practice Location

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