Provider Demographics
NPI:1326067703
Name:SELF REGIONAL HEALTHCARE
Entity Type:Organization
Organization Name:SELF REGIONAL HEALTHCARE
Other - Org Name:MONTGOMERY CENTER FOR FAMILY MEDICINE OF SRH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-725-4253
Mailing Address - Street 1:155 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3808
Mailing Address - Country:US
Mailing Address - Phone:864-725-4865
Mailing Address - Fax:864-725-4883
Practice Address - Street 1:155 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3869
Practice Address - Country:US
Practice Address - Phone:864-725-4865
Practice Address - Fax:864-725-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CE6182OtherMEDICARE RR GROUP NUMBER
SCPC3251Medicaid
SC1127Medicare PIN