Healthcare Provider Details

I. General information

NPI: 1265740765
Provider Name (Legal Business Name): LOGAN PHYSICIAN PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 SUGAR MAPLE DRIVE
AUBURN KY
42206
US

IV. Provider business mailing address

128 SUGAR MAPLE DRIVE
AUBURN KY
42206
US

V. Phone/Fax

Practice location:
  • Phone: 615-957-0847
  • Fax:
Mailing address:
  • Phone: 615-957-0847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY J TEAGUE
Title or Position: VICE PRESIDENT AND CORP SECRETARY
Credential:
Phone: 629-253-5121