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General NPI Number Information
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NPI Number | 1225838733
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Entity Type | Organization
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Legal Business Name | SELF REGIONAL HEALTHCARE
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Dates
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Enumeration Date | 03/14/2025
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Last Update Date | 03/14/2025
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Provider Practice Location Address
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Address Line | 106 LINER DR
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City | GREENWOOD
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State | SC
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Zip | 29646-2310
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Country | US
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Telephone | 864-227-6371
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Fax | 864-227-6345
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Provider Business Mailing Address
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Address Line | 104 WELLS AVE
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City | GREENWOOD
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State | SC
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Zip | 29646-3837
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Country | US
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Telephone | 864-725-4673
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Fax | 864-725-7424
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | MATTHEW TOLBERT LOGAN
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Credential |
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Telephone | 864-725-4780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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