Basic Information
Provider Information | |||||||||
NPI: | 1952772253 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SELF MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ORTHOPAEDIC ASSOCIATES OF THE LAKELANDS, A DIVISION OF SELF MEDICAL | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 102 GREGOR MENDEL CIR | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD | ||||||||
State: | SC | ||||||||
PostalCode: | 296462315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642292663 | ||||||||
FaxNumber: | 8642230536 | ||||||||
Practice Location | |||||||||
Address1: | 102 GREGOR MENDEL CIR | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD | ||||||||
State: | SC | ||||||||
PostalCode: | 296462315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642292663 | ||||||||
FaxNumber: | 8642230539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2015 | ||||||||
LastUpdateDate: | 06/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOGAN | ||||||||
AuthorizedOfficialFirstName: | MATTHEW | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8647254253 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0005X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.