Healthcare Provider Details

I. General information

NPI: 1184622912
Provider Name (Legal Business Name): MARY JO LOGEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3373 COMMERCE PKWY SUITE 2
WOOSTER OH
44691-7130
US

IV. Provider business mailing address

3373 COMMERCE PKWY SUITE 2
WOOSTER OH
44691-7130
US

V. Phone/Fax

Practice location:
  • Phone: 330-804-9712
  • Fax: 330-804-9717
Mailing address:
  • Phone: 330-804-9712
  • Fax: 330-804-9717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number35061022
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: