Provider Demographics
NPI:1588603682
Name:LOGAN, WILLIAM C JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:LOGAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S. PINE STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1972
Mailing Address - Country:US
Mailing Address - Phone:864-327-1510
Mailing Address - Fax:864-327-1662
Practice Address - Street 1:103 S. PINE STREET
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1972
Practice Address - Country:US
Practice Address - Phone:864-327-1510
Practice Address - Fax:864-327-1662
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23138207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT72123Medicaid
SCF599075770Medicare PIN
SCT72123Medicaid