Healthcare Provider Details

I. General information

NPI: 1487614152
Provider Name (Legal Business Name): LOGAN VIEW PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 DOWELL AVE
BELLEFONTAINE OH
43311-2305
US

IV. Provider business mailing address

118 DOWELL AVE
BELLEFONTAINE OH
43311-2305
US

V. Phone/Fax

Practice location:
  • Phone: 937-593-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMARA GUMP
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 937-593-0245