Healthcare Provider Details

I. General information

NPI: 1427054873
Provider Name (Legal Business Name): THEODORE P. LOGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 UNION ST
ROCKLAND ME
04841-2739
US

IV. Provider business mailing address

300 SOUTHBOROUGH DR SUITE 201
SOUTH PORTLAND ME
04106-6914
US

V. Phone/Fax

Practice location:
  • Phone: 207-701-4400
  • Fax: 207-701-4487
Mailing address:
  • Phone: 207-661-2018
  • Fax: 207-661-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number012617
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD12617
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD12617
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: