MEDICARE: LOGAN PHYSICIAN PRACTICE LLC

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	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1427720994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGAN PHYSICIAN PRACTICE LLC

Provider Business Mailing Address
First Line	:	680 S 4TH ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-2407
Country	:	US
Telephone Number	:	502-596-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 S MAIN ST
Second Line	:
City	:	ELKTON
State	:	KY
Zip	:	42220-8863
Country	:	US
Telephone Number	:	270-265-5023
Fax Number	:	270-265-5026

Authorized Official
Title or Position	:	VICE PRESIDENT AND CORP SECRETARY
Name	:	KATHY J TEAGUE
Credential	:
Telephone Number	:	629-253-5121

Provider Enumeration Date	:	10/01/2021
Last Update Date	:	07/03/2024

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Directions to “LOGAN PHYSICIAN PRACTICE LLC ” Practice Location

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