Healthcare Provider Details

I. General information

NPI: 1376041798
Provider Name (Legal Business Name): SELF MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4111
  • Fax: 864-725-7498
Mailing address:
  • Phone: 864-725-4111
  • Fax: 864-725-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW T LOGAN
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 864-725-4253