Healthcare Provider Details

I. General information

NPI: 1134981947
Provider Name (Legal Business Name): SELF MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 SPRING ST
GREENWOOD SC
29646-3831
US

IV. Provider business mailing address

1015 SPRING ST
GREENWOOD SC
29646-3831
US

V. Phone/Fax

Practice location:
  • Phone: 864-227-6741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

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