Healthcare Provider Details

I. General information

NPI: 1598753014
Provider Name (Legal Business Name): SAMUEL L OGDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109B ALLEN MEMORIAL DR
BREMEN GA
30110-2009
US

IV. Provider business mailing address

109B ALLEN MEMORIAL DR
BREMEN GA
30110-2009
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-4900
  • Fax: 770-537-0907
Mailing address:
  • Phone: 770-537-4900
  • Fax: 770-537-0907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberO30170
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: