MEDICARE: MR. MARK P LOGUE CPO

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	174400000X	Specialist	POR161	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00178	OTHER	FL	QUALITY HEALTH CARE
2	M0692	OTHER	FL	BLUE CROSS BLUE SHIELD
3	00124	OTHER	FL	UNIVERSAL HEALTHCARE

General Provider Information

NPI Number	:	1669685301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK P LOGUE CPO

Provider Business Mailing Address
First Line	:	2214 DONATO DR
Second Line	:
City	:	BELLEAIR BEACH
State	:	FL
Zip	:	33786-3433
Country	:	US
Telephone Number	:	727-449-9292
Fax Number	:	727-449-9393

Provider Business Practice Location Address
First Line	:	516 LAKEVIEW RD
Second Line	:	VILLA 1
City	:	CLEARWATER
State	:	FL
Zip	:	33756-3302
Country	:	US
Telephone Number	:	727-449-9292
Fax Number	:	727-449-9393

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	01/09/2008

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