Provider Demographics
NPI:1275967077
Name:LOGAN GRADDY MD PLLC
Entity Type:Organization
Organization Name:LOGAN GRADDY MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-475-9160
Mailing Address - Street 1:910 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4142
Mailing Address - Country:US
Mailing Address - Phone:919-416-4191
Mailing Address - Fax:888-805-6175
Practice Address - Street 1:910 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4142
Practice Address - Country:US
Practice Address - Phone:919-416-4191
Practice Address - Fax:888-805-6175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007000070261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)