Provider Demographics
NPI:1336598028
Name:ANDREA LOGAN MD
Entity Type:Organization
Organization Name:ANDREA LOGAN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:F
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-818-0585
Mailing Address - Street 1:3631 BIENVILLE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5702
Mailing Address - Country:US
Mailing Address - Phone:228-818-0585
Mailing Address - Fax:228-818-0588
Practice Address - Street 1:3631 BIENVILLE BLVD STE B
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5702
Practice Address - Country:US
Practice Address - Phone:228-818-0585
Practice Address - Fax:228-818-0588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21719208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty