Healthcare Provider Details

I. General information

NPI: 1962805432
Provider Name (Legal Business Name): LOGAN RECKORD SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CENTENNIAL BLVD #202
VOORHEES NJ
08043-4637
US

IV. Provider business mailing address

3130 W MASTER ST
PHILADELPHIA PA
19121-4424
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2034
  • Fax:
Mailing address:
  • Phone: 717-283-6162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00345600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: