Healthcare Provider Details

I. General information

NPI: 1538488457
Provider Name (Legal Business Name): SELF MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 SPRING ST
GREENWOOD SC
29646-4071
US

IV. Provider business mailing address

105 VINECREST CT # 500
GREENWOOD SC
29646-8031
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-7900
  • Fax: 864-725-7910
Mailing address:
  • Phone: 864-725-7900
  • Fax: 864-725-7910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) 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