Healthcare Provider Details

I. General information

NPI: 1689965204
Provider Name (Legal Business Name): LOGAN JAMES MCGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2011
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 VILLAGE DR
COTTAGE GROVE OR
97424-9700
US

IV. Provider business mailing address

13500 AIRPORT RD
BOONVILLE CA
95415-9133
US

V. Phone/Fax

Practice location:
  • Phone: 541-767-5200
  • Fax: 541-767-5200
Mailing address:
  • Phone: 707-895-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD181244
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: