1730117896 NPI number — LOGAN INTERNAL MEDICINE GROUP

Table of content: (NPI 1730117896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730117896 NPI number — LOGAN INTERNAL MEDICINE GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN INTERNAL MEDICINE GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LOGAN INTERNAL MEDICINE GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730117896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1617
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25601-1617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-831-0450
Provider Business Mailing Address Fax Number:
304-831-0452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-831-0450
Provider Business Practice Location Address Fax Number:
304-831-0452
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ-RAMOS
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-831-0450

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810011047 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001860338 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001860338 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DF2728 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 438170 . This is a "ADVANTRA FREEDOM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 438170 . This is a "COVENTRY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 611399500 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".




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