Healthcare Provider Details

I. General information

NPI: 1205820008
Provider Name (Legal Business Name): ALEXANDRA LOGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-5067
  • Fax: 585-922-2908
Mailing address:
  • Phone: 585-922-5067
  • Fax: 585-922-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number251865
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number251865
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: