1023123346 NPI number — LOGAN PRIMARY CARE SERVICE CORP.

Table of content: (NPI 1023123346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023123346 NPI number — LOGAN PRIMARY CARE SERVICE CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN PRIMARY CARE SERVICE CORP.
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:
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:
1023123346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 RUSHING DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERRIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-993-3300
Provider Business Mailing Address Fax Number:
618-997-6626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 W ST LOUIS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST FRANKFORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-997-3400
Provider Business Practice Location Address Fax Number:
618-932-3797
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEATON
Authorized Official First Name:
TARA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
618-993-3300

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  036099669 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 148969 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10019630 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com