Provider Demographics
NPI:1326074592
Name:VILLAGE INTERNAL MEDICINE, PA
Entity Type:Organization
Organization Name:VILLAGE INTERNAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:LOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-483-8080
Mailing Address - Street 1:1843 QUIET CV
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3857
Mailing Address - Country:US
Mailing Address - Phone:910-483-8080
Mailing Address - Fax:910-483-3258
Practice Address - Street 1:1843 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-483-8080
Practice Address - Fax:910-483-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC62468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890296PMedicaid
NC2318305Medicare ID - Type Unspecified