1154321867 NPI number — SCOTT D LOGAN MD

Table of content: SCOTT D LOGAN MD (NPI 1154321867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154321867 NPI number — SCOTT D LOGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOGAN
Provider First Name:
SCOTT
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1154321867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1735 27TH ST STE B06
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45662-2681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-356-8681
Provider Business Mailing Address Fax Number:
740-356-7900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1805 27TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-356-8117
Provider Business Practice Location Address Fax Number:
740-353-1214
Provider Enumeration Date:
07/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  35077928 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: MC-167 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00187419 . This is a "SOM RR MDCR PIN NO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2207472 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64029481 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118982200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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