Healthcare Provider Details

I. General information

NPI: 1982139705
Provider Name (Legal Business Name): WREN WILLOW LOGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2017
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3948 N SHERIDAN RD
CHICAGO IL
60613-2935
US

IV. Provider business mailing address

3948 N SHERIDAN RD
CHICAGO IL
60613-2935
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8936
Mailing address:
  • Phone: 773-388-1600
  • Fax: 773-388-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036.160349
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: