Provider Demographics
NPI:1104572411
Name:SELF MEDICAL GROUP
Entity type:Organization
Organization Name:SELF MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-725-4253
Mailing Address - Street 1:410 EPTING AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4040
Mailing Address - Country:US
Mailing Address - Phone:864-725-5326
Mailing Address - Fax:864-725-5327
Practice Address - Street 1:410 EPTING AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4040
Practice Address - Country:US
Practice Address - Phone:864-725-5326
Practice Address - Fax:864-725-5327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty