MEDICARE: LOGAN GENERAL MEDICAL CENTER INC

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	207Q00000X	Family Medicine Physician	1768840	IL

General Provider Information

NPI Number	:	1497834139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGAN GENERAL MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	2734 N MILWAUKEE AVE
Second Line	:	150
City	:	CHICAGO
State	:	IL
Zip	:	60647-1362
Country	:	US
Telephone Number	:	773-384-2445
Fax Number	:	773-384-1155

Provider Business Practice Location Address
First Line	:	2734 N MILWAUKEE AVE
Second Line	:	150
City	:	CHICAGO
State	:	IL
Zip	:	60647-1362
Country	:	US
Telephone Number	:	773-384-2445
Fax Number	:	773-384-1155

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROSANGEL PEREZ
Credential	:
Telephone Number	:	773-384-2445

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	08/22/2020

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