Provider Demographics
NPI:1649203043
Name:LOGAN PHYSICIAN PRACTICE LLC
Entity Type:Organization
Organization Name:LOGAN PHYSICIAN PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-253-5121
Mailing Address - Street 1:113 SEABOARD LN STE 201B
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-8284
Mailing Address - Country:US
Mailing Address - Phone:629-253-5121
Mailing Address - Fax:
Practice Address - Street 1:975 HOPKINSVILLE RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-9792
Practice Address - Country:US
Practice Address - Phone:270-726-2738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935777Medicaid
KY9441Medicare PIN
KY9441Medicare ID - Type Unspecified