Provider Demographics
NPI:1013914241
Name:LOGAN, SAMUEL ERNEST (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ERNEST
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 STONEGATE PARK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9137
Mailing Address - Country:US
Mailing Address - Phone:269-556-6000
Mailing Address - Fax:
Practice Address - Street 1:3901 STONEGATE PARK
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9137
Practice Address - Country:US
Practice Address - Phone:269-556-6000
Practice Address - Fax:269-556-6020
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056980208200000X, 2082S0105X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2663684Medicaid
MI1013914241Medicaid
MIMI2051Medicare PIN
MIA12812Medicare ID - Type Unspecified