Healthcare Provider Details

I. General information

NPI: 1629018387
Provider Name (Legal Business Name): JONATHAN ROY LOGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LOCUST AVE
FAIRMONT WV
26554-1435
US

IV. Provider business mailing address

6005 WOOLAND BLUFFS DRIVE
MORGANTOWN WV
26508
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101243177
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20682
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: