Healthcare Provider Details

I. General information

NPI: 1689472292
Provider Name (Legal Business Name): SELF REGIONAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 R L SAWYER MD DR
SALUDA SC
29138-9199
US

IV. Provider business mailing address

104 WELLS AVE
GREENWOOD SC
29646-3837
US

V. Phone/Fax

Practice location:
  • Phone: 864-445-2173
  • Fax: 864-445-9158
Mailing address:
  • Phone: 864-725-4673
  • Fax: 864-725-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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