MEDICARE: KEITH LOGAN MD

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	2084P0800X	Psychiatry Physician	9800612	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134191463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH LOGAN MD

Provider Business Mailing Address
First Line	:	7804 FAIRVIEW RD STE C
Second Line	:	PMB 302
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4999
Country	:	US
Telephone Number	:	704-541-1213
Fax Number	:	704-541-4210

Provider Business Practice Location Address
First Line	:	2701 COLTSGATE RD
Second Line	:	#105
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3534
Country	:	US
Telephone Number	:	704-541-1213
Fax Number	:	704-541-4210

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	08/05/2011

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