MEDICARE: TINA M LOGAN RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTH 3715	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71-0945220	OTHER	AL	EMPLOYER TAX ID
2	63-1196634	OTHER	AL	EMPLOYER TAX ID

General Provider Information

NPI Number	:	1073654778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA M LOGAN RPT

Provider Business Mailing Address
First Line	:	1200 CORPORATE DR STE 400
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35242-5424
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:

Provider Business Practice Location Address
First Line	:	2555 HIGHWAY 78 E
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35501-3433
Country	:	US
Telephone Number	:	205-385-7919
Fax Number	:	205-803-6458

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	09/21/2023

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Directions to “ TINA M LOGAN RPT” Practice Location

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