Healthcare Provider Details

I. General information

NPI: 1710786066
Provider Name (Legal Business Name): SELF REGIONAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 SPRING ST
GREENWOOD SC
29646-3831
US

IV. Provider business mailing address

104 WELLS AVE
GREENWOOD SC
29646-3837
US

V. Phone/Fax

Practice location:
  • Phone: 864-227-6741
  • Fax: 864-227-2046
Mailing address:
  • Phone: 864-725-4673
  • Fax: 864-725-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW TOLBERT LOGAN
Title or Position: PRESIDENT & CEO
Credential:
Phone: 864-725-4780