Provider Demographics
NPI:1134442890
Name:SELF MEDICAL GROUP
Entity type:Organization
Organization Name:SELF MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND 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 1:115 ACADEMY AVENUE
Mailing Address - Street 2:UNIT A
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646
Mailing Address - Country:US
Mailing Address - Phone:864-725-7272
Mailing Address - Fax:864-725-5764
Practice Address - Street 1:115 ACADEMY AVENUE
Practice Address - Street 2:UNIT A
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646
Practice Address - Country:US
Practice Address - Phone:864-725-7272
Practice Address - Fax:864-725-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2021-12-14
Deactivation Date:2012-05-22
Deactivation Code:
Reactivation Date:2013-09-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5374Medicaid
SCGP5374Medicaid