Healthcare Provider Details

I. General information

NPI: 1164965042
Provider Name (Legal Business Name): PAMELA LOGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 ATHENS ST
GAINESVILLE GA
30507-7000
US

IV. Provider business mailing address

1290 ATHENS ST
GAINESVILLE GA
30507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 770-531-5600
  • Fax:
Mailing address:
  • Phone: 770-531-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number41406
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: