Provider Demographics
NPI:1992893416
Name:LOGAN MEMORIAL HOSPITAL LLC
Entity type:Organization
Organization Name:LOGAN MEMORIAL HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-6063
Mailing Address - Street 1:680 S 4TH ST # KH-3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:502-596-6063
Mailing Address - Fax:
Practice Address - Street 1:1625 NASHVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-8853
Practice Address - Country:US
Practice Address - Phone:270-726-4011
Practice Address - Fax:270-726-7465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY73282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5000013OtherUNITED HEALTHCARE
KY1096575OtherPASSPORT HEALTH
KY166291400OtherACS
KY000000055027OtherBLUE CROSS
KY360698OtherBLACK LUNG
KY000000342028OtherBLUE CROSS LABORATORY
KY01000132Medicaid
TN0180066Medicaid
IN100038770AMedicaid
KYKYMCO11BOtherWORKERS COMP
IN100038770AMedicaid