=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992893416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOGAN MEMORIAL HOSPITAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 06/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 NASHVILLE ST
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42276-8853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-726-4011
-----------------------------------------------------
Fax | 270-726-7465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 S 4TH ST # KH-3
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-596-6063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AO
-----------------------------------------------------
Name | JOHNETTA TRAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-596-6063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NR1301X
-----------------------------------------------------
Taxonomy Name | Rural Acute Care Hospital
-----------------------------------------------------
License Number | 73
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------