Healthcare Provider Details

I. General information

NPI: 1003117078
Provider Name (Legal Business Name): MARK E LOGAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 STRATTON RD
RUTLAND VT
05701-4621
US

IV. Provider business mailing address

199 STRATTON RD
RUTLAND VT
05701-4621
US

V. Phone/Fax

Practice location:
  • Phone: 802-775-7798
  • Fax: 802-775-7762
Mailing address:
  • Phone: 802-775-7798
  • Fax: 802-775-7762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number042-0006819
License Number StateVT

VIII. Authorized Official

Name: MARK E LOGAN
Title or Position: OWNER
Credential: MD
Phone: 802-775-7798