Healthcare Provider Details

I. General information

NPI: 1013914241
Provider Name (Legal Business Name): SAMUEL ERNEST LOGAN M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 STONEGATE PARK SUITE 300
SAINT JOSEPH MI
49085-9137
US

IV. Provider business mailing address

3901 STONEGATE PARK SUITE 300
SAINT JOSEPH MI
49085-9137
US

V. Phone/Fax

Practice location:
  • Phone: 269-556-6000
  • Fax: 269-556-6020
Mailing address:
  • Phone: 269-556-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301056980
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number4301056980
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301056980
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: