MEDICARE: ALEXANDRA LOGAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	251865	NY
2	207R00000X	Internal Medicine Physician	251865	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205820008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA LOGAN MD

Provider Business Mailing Address
First Line	:	1425 PORTLAND AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-3001
Country	:	US
Telephone Number	:	585-922-5067
Fax Number	:	585-922-2908

Provider Business Practice Location Address
First Line	:	1425 PORTLAND AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-3001
Country	:	US
Telephone Number	:	585-922-5067
Fax Number	:	585-922-2908

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	11/12/2018

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