Healthcare Provider Details

I. General information

NPI: 1952772253
Provider Name (Legal Business Name): SELF MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 GREGOR MENDEL CIR
GREENWOOD SC
29646-2315
US

IV. Provider business mailing address

102 GREGOR MENDEL CIR
GREENWOOD SC
29646-2315
US

V. Phone/Fax

Practice location:
  • Phone: 864-229-2663
  • Fax: 864-223-0539
Mailing address:
  • Phone: 864-229-2663
  • Fax: 864-223-0536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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