Provider Demographics
NPI:1730117896
Name:LOGAN INTERNAL MEDICINE GROUP
Entity Type:Organization
Organization Name:LOGAN INTERNAL MEDICINE GROUP
Other - Org Name:LOGAN INTERNAL MEDICINE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:GONZALEZ-RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-831-0450
Mailing Address - Street 1:PO BOX 1617
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-1617
Mailing Address - Country:US
Mailing Address - Phone:304-831-0450
Mailing Address - Fax:304-831-0452
Practice Address - Street 1:77 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3451
Practice Address - Country:US
Practice Address - Phone:304-831-0450
Practice Address - Fax:304-831-0452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011047Medicaid
001860338OtherBCBS OF MICHIGAN
001860338OtherMOUNTAIN STATE BCBS
WVDF2728OtherRR MEDICARE
438170OtherADVANTRA FREEDOM
438170OtherCOVENTRY HEALTH
611399500OtherBLACK LUNG
438170OtherADVANTRA FREEDOM
WV3810011047Medicaid