Basic Information
| Provider Information | |||||||||
| NPI: | 1609262807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SELF MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | FAMILY HEALTHCARE NINETY SIX, A DIVISION OF SELF MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 LITTLE MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | NINETY SIX | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296669252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645433515 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 LITTLE MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | NINETY SIX | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296669252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645433515 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | LOGAN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8647254253 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.