MEDICARE: DR. JONATHAN ROY LOGAN M.D.

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	207P00000X	Emergency Medicine Physician	0101243177	VA
2	207P00000X	Emergency Medicine Physician	20682	WV

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

General Provider Information

NPI Number	:	1629018387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN ROY LOGAN M.D.

Provider Business Mailing Address
First Line	:	6005 WOOLAND BLUFFS DRIVE
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26508
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 LOCUST AVE
Second Line	:
City	:	FAIRMONT
State	:	WV
Zip	:	26554-1435
Country	:	US
Telephone Number	:	304-367-7100
Fax Number	:

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	11/17/2021

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