MEDICARE: SELF MEDICAL GROUP

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	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1205475688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1123 SPRING ST
Second Line	:
City	:	GREENWOOD
State	:	SC
Zip	:	29646-3833
Country	:	US
Telephone Number	:	864-450-9036
Fax Number	:	864-450-9038

Provider Business Practice Location Address
First Line	:	1123 SPRING ST
Second Line	:
City	:	GREENWOOD
State	:	SC
Zip	:	29646-3833
Country	:	US
Telephone Number	:	864-450-9036
Fax Number	:	864-450-9038

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	DR. MATTHEW T LOGAN
Credential	:
Telephone Number	:	864-725-4253

Provider Enumeration Date	:	01/02/2020
Last Update Date	:	12/14/2021

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Directions to “SELF MEDICAL GROUP ” Practice Location

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