Provider Demographics
NPI:1821105974
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:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-993-3300
Mailing Address - Street 1:405 RUSHING DRIVE
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 DRIVE
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:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D0666068OtherCLIA
IL143870Medicaid
14D0436594OtherCLIA
14D0963522OtherCLIA
IL10019630OtherBLUE CROSS BLUE SHIELD
14D1041426OtherCLIA
H10113Medicare UPIN
14D0436594OtherCLIA
IL10019630OtherBLUE CROSS BLUE SHIELD
336570Medicare ID - Type Unspecified