MEDICARE: MR. LOGAN BROWN ATC, LAT

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	2255A2300X	Athletic Trainer	096.005094	IL
2	390200000X	Student in an Organized Health Care Education/Training Program		KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B09-958-702	OTHER	KY	DRIVERS LICENSE

General Provider Information

NPI Number	:	1548728116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LOGAN BROWN ATC, LAT

Provider Business Mailing Address
First Line	:	2430 W WARNER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-2812
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 W WARNER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-2812
Country	:	US
Telephone Number	:	502-648-1164
Fax Number	:

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

Provider Enumeration Date	:	03/03/2019
Last Update Date	:	07/26/2021

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