Provider Demographics
NPI:1093017196
Name:MICHAEL J. LOGAN MD, SC
Entity Type:Organization
Organization Name:MICHAEL J. LOGAN MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-786-1710
Mailing Address - Street 1:15065 WESTOVER RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1541
Mailing Address - Country:US
Mailing Address - Phone:262-786-1710
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5906
Practice Address - Country:US
Practice Address - Phone:262-789-0909
Practice Address - Fax:262-821-6180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16418-20261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000068456Medicare PIN