Healthcare Provider Details

I. General information

NPI: 1699137786
Provider Name (Legal Business Name): LOGAN D FAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST STE 500
JACKSON MS
39202-1615
US

IV. Provider business mailing address

501 MARSHALL ST STE 500
JACKSON MS
39202-1615
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-1411
  • Fax: 601-948-0090
Mailing address:
  • Phone: 601-948-1411
  • Fax: 601-948-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number28954
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: