Healthcare Provider Details

I. General information

NPI: 1992951123
Provider Name (Legal Business Name): LOGAN PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
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: 618-993-0262
Mailing address:
  • Phone: 618-993-3300
  • Fax: 618-993-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-003043
License Number StateIL

VIII. Authorized Official

Name: MICAH OAKLEY
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 618-993-3300