Provider Demographics
NPI:1720475221
Name:SELF MEDICAL GROUP
Entity Type:Organization
Organization Name:SELF MEDICAL GROUP
Other - Org Name:PEDIATRIC ASSOCIATES GREENWOOD, A DIVISION OF SELF MEDICAL GROUP
Other - Org Type:Other Name
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 1:210 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3843
Mailing Address - Country:US
Mailing Address - Phone:864-943-4279
Mailing Address - Fax:864-223-2642
Practice Address - Street 1:210 WELLS AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3843
Practice Address - Country:US
Practice Address - Phone:864-943-4279
Practice Address - Fax:864-223-2642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty