Provider Demographics
NPI:1588969448
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 CHIEF EXECUTIVE OFFIC
Authorized Official - Prefix:DR
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 1:104 LINER DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646
Mailing Address - Country:US
Mailing Address - Phone:864-227-1115
Mailing Address - Fax:864-227-2046
Practice Address - Street 1:104 LINER DRIVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646
Practice Address - Country:US
Practice Address - Phone:864-227-1115
Practice Address - Fax:864-227-2046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELF MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-24
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9337Medicare PIN
9337Medicare PIN