MEDICARE: MARK EDWARD LOGAN

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1457022998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EDWARD LOGAN

Provider Business Mailing Address
First Line	:	3823 MAIN ST
Second Line	:
City	:	CHINCOTEAGUE
State	:	VA
Zip	:	23336-1857
Country	:	US
Telephone Number	:	757-336-2844
Fax Number	:	757-336-2811

Provider Business Practice Location Address
First Line	:	3823 MAIN ST
Second Line	:
City	:	CHINCOTEAGUE
State	:	VA
Zip	:	23336-1857
Country	:	US
Telephone Number	:	757-336-2844
Fax Number	:	757-336-2811

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

Provider Enumeration Date	:	09/24/2021
Last Update Date	:	09/24/2021

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Directions to “ MARK EDWARD LOGAN ” Practice Location

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