Healthcare Provider Details

I. General information

NPI: 1538036314
Provider Name (Legal Business Name): SELF REGIONAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2025
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ACADEMY AVE
GREENWOOD SC
29646-3869
US

IV. Provider business mailing address

104 WELLS AVE
GREENWOOD SC
29646-3837
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-7272
  • Fax: 864-725-5799
Mailing address:
  • Phone: 864-725-4673
  • Fax: 864-725-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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