Healthcare Provider Details

I. General information

NPI: 1881630655
Provider Name (Legal Business Name): JAMES J LOGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 FORSYTH ST SUITE 2C
MACON GA
31201-8637
US

IV. Provider business mailing address

1062 FORSYTH ST SUITE 2-C
MACON GA
31201-8637
US

V. Phone/Fax

Practice location:
  • Phone: 478-755-0036
  • Fax: 478-755-1254
Mailing address:
  • Phone: 478-755-0036
  • Fax: 478-755-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number040465
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: