Provider Demographics
NPI:1508824517
Name:LOGIO, LIA S (MD)
Entity Type:Individual
Prefix:DR
First Name:LIA
Middle Name:S
Last Name:LOGIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CHERRY ST STE 11511
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1310
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:
Practice Address - Street 1:1427 VINE ST FL 6
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD463563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200371590Medicaid
IN200371590Medicaid
IN715530O1Medicare PIN