Provider Demographics
NPI:1902868078
Name:LOGAN, MATTHEW TOLBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TOLBERT
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 TRYON CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-7200
Mailing Address - Country:US
Mailing Address - Phone:864-229-1216
Mailing Address - Fax:
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:SELF REGIONAL HEALTHCARE, DEPT. OF EMERGENCY MEDICINE
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23221207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC232215Medicaid
SCH85174Medicare UPIN
SCH851741124Medicare PIN