Healthcare Provider Details

I. General information

NPI: 1194913541
Provider Name (Legal Business Name): LOGAN PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 RUSHING DR
HERRIN IL
62948-3730
US

IV. Provider business mailing address

405 RUSHING DR
HERRIN IL
62948-3730
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-3300
  • Fax: 618-997-6626
Mailing address:
  • Phone: 618-993-3300
  • Fax: 618-997-6626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85003043
License Number StateIL

VIII. Authorized Official

Name: MRS. TARA DEATON
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-993-3300