Provider Demographics
NPI:1750338919
Name:LOGUE, MICHAEL STEPHEN (FAM NRS PRAC FNP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:LOGUE
Suffix:
Gender:M
Credentials:FAM NRS PRAC FNP
Other - Prefix:
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Mailing Address - Street 1:11140 S TOWNE SQUARE
Mailing Address - Street 2:SUITE # 105
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123
Mailing Address - Country:US
Mailing Address - Phone:314-894-0787
Mailing Address - Fax:314-729-3963
Practice Address - Street 1:10012 KENNERLY ROAD
Practice Address - Street 2:SUITE # 301
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-894-0787
Practice Address - Fax:314-729-1489
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO135879363LF0000X
IL209004468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO652432OtherHEALTHLINK
MO429176605Medicaid
MO46286OtherHEALTHCARE USA
MO189482OtherBCBS
MO7196539OtherAETNA
MOP00117390OtherMEDICARE RAILROAD
MO072289OtherEXCLUSIVE CHOICE
IL356650631001Medicaid
MO46286OtherHEALTHCARE USA
MO817872159Medicare ID - Type Unspecified
MO429176605Medicaid
ILK06576Medicare ID - Type Unspecified