Provider Demographics
NPI:1477880003
Name:SELF MEDICAL GROUP
Entity Type:Organization
Organization Name:SELF MEDICAL GROUP
Other - Org Name:FAMILY HEALTHCARE NEWBERRY, A DIVISION OF SELF MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CHIEF EXECUTIVE OFFIC
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 1:2605 KINARD STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2967
Mailing Address - Country:US
Mailing Address - Phone:803-405-1900
Mailing Address - Fax:803-405-1919
Practice Address - Street 1:2605 KINARD STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2967
Practice Address - Country:US
Practice Address - Phone:803-405-1900
Practice Address - Fax:803-405-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QR1300X
SCRHC208261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5316Medicaid
SCGP5316Medicaid
9337Medicare PIN