1396899167 NPI number — LAURA J LOGUE AOCNP

Table of content: LAURA J LOGUE AOCNP (NPI 1396899167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396899167 NPI number — LAURA J LOGUE AOCNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOGUE
Provider First Name:
LAURA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AOCNP
Provider Gender Code:
F

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:
1396899167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1411 LANEY WALKER BLVD. AN 2206
Provider Second Line Business Mailing Address:
MCG CANCER CENTER
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30912-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-721-4811
Provider Business Mailing Address Fax Number:
706-721-0671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 LANEY WALKER BLVD # AN2206
Provider Second Line Business Practice Location Address:
MCG CANCER CENTER
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30912-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-721-4811
Provider Business Practice Location Address Fax Number:
706-721-0671
Provider Enumeration Date:
01/22/2007

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: 363L00000X , with the licence number:  RN196130 NP , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003104396B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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