Provider Demographics
NPI:1730296880
Name:LOGAN PRIMARY CARE SERVICE CORPORATION
Entity Type:Organization
Organization Name:LOGAN PRIMARY CARE SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:GAYEL
Authorized Official - Last Name:DEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-993-3300
Mailing Address - Street 1:405 RUSHING DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-993-3300
Mailing Address - Fax:618-997-6626
Practice Address - Street 1:405 RUSHING DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-993-3300
Practice Address - Fax:618-997-6626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143870Medicaid
E26544Medicare UPIN
IL143870Medicaid