Provider Demographics
NPI:1083707616
Name:LOGUE, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LOGUE
Suffix:
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 1:10513 SILVERDALE WAY NW
Mailing Address - Street 2:STE 101
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383
Mailing Address - Country:US
Mailing Address - Phone:360-692-1848
Mailing Address - Fax:360-692-1912
Practice Address - Street 1:10513 SILVERDALE WAY NW
Practice Address - Street 2:STE 101
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-692-1848
Practice Address - Fax:360-692-1912
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8262529Medicaid
GAB21640Medicare PIN
WAH36159Medicare UPIN
GAB21729Medicare PIN
G8872438Medicare PIN
G8871769Medicare PIN
GAB21730Medicare PIN