Healthcare Provider Details

I. General information

NPI: 1215246350
Provider Name (Legal Business Name): SELF MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 EPTING AVE
GREENWOOD SC
29646-4041
US

IV. Provider business mailing address

421 EPTING AVE
GREENWOOD SC
29646-4041
US

V. Phone/Fax

Practice location:
  • Phone: 864-227-6818
  • Fax:
Mailing address:
  • Phone: 864-227-6818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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