Healthcare Provider Details

I. General information

NPI: 1366374506
Provider Name (Legal Business Name): LOGAN HANBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3858 HILLCREST LN
MOBILE AL
36693-2830
US

IV. Provider business mailing address

3858 HILLCREST LN
MOBILE AL
36693-2830
US

V. Phone/Fax

Practice location:
  • Phone: 251-222-1091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1-197213
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: