Provider Demographics
NPI:1063492197
Name:LOGAN, ALEXANDER C III (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:C
Last Name:LOGAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3099
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-3099
Mailing Address - Country:US
Mailing Address - Phone:843-716-7000
Mailing Address - Fax:843-716-7272
Practice Address - Street 1:3655 MITCHELL ST
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2827
Practice Address - Country:US
Practice Address - Phone:843-716-7000
Practice Address - Fax:843-716-7272
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14453207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC690543PMedicaid
SC144539Medicaid
220024587Medicare PIN
SCE72836Medicare UPIN
SC144539Medicaid