=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477395259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOGAN GIESIGE CSA, CSFA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2024
-----------------------------------------------------
Last Update Date | 06/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5801 BREMO RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23226-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 840-285-2011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 KARL LINN DR APT 101
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-6973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-279-0633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 0136000941
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------