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General NPI Number Information
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NPI Number | 1538488457
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Entity Type | Organization
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Legal Business Name | SELF MEDICAL GROUP
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Dates
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Enumeration Date | 05/18/2010
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Last Update Date | 05/31/2024
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Provider Practice Location Address
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Address Line | 1506 SPRING ST
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City | GREENWOOD
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State | SC
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Zip | 29646-4071
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Country | US
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Telephone | 864-725-7900
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Fax | 864-725-7910
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Provider Business Mailing Address
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Address Line | 105 VINECREST CT # 500
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City | GREENWOOD
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State | SC
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Zip | 29646-8031
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Country | US
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Telephone | 864-725-7900
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Fax | 864-725-7910
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Authorized Official
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Title or Position | PRESIDENT AND CHIEF EXECUTIVE OFFIC
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Name | DR. MATTHEW T LOGAN
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Credential | MD
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Telephone | 864-725-4253
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery 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 | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number |
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License Number State |
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