Provider Demographics
NPI:1467214049
Name:SELF MEDICAL GROUP
Entity Type:Organization
Organization Name:SELF MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:TOLBERT
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-725-4780
Mailing Address - Street 1:22580 HIGHWAY 76 E STE 200
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-8460
Mailing Address - Country:US
Mailing Address - Phone:864-833-0055
Mailing Address - Fax:
Practice Address - Street 1:22580 HIGHWAY 76 E STE 200
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-8460
Practice Address - Country:US
Practice Address - Phone:864-833-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty