Provider Demographics
NPI:1326274507
Name:LOGAN UROLOGY CLINIC
Entity Type:Organization
Organization Name:LOGAN UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-753-1171
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:STE J
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-753-1171
Mailing Address - Fax:435-792-4464
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:STE J
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-753-1171
Practice Address - Fax:435-792-4464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOGAN UROLOGY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175141-1205302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID340017516Medicaid
UT08582Medicaid
UT08582Medicaid
UT87732Medicare UPIN