Healthcare Provider Details

I. General information

NPI: 1821483298
Provider Name (Legal Business Name): LOGAN EDMONDS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 07/21/2022
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL WAY STE 100
SOMERSET KY
42503-1872
US

IV. Provider business mailing address

5200 COMMERCE CROSSINGS DR FL 3
LOUISVILLE KY
40229-2182
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-2600
  • Fax:
Mailing address:
  • Phone: 502-253-4924
  • Fax: 502-489-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberE04041055
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04101
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: