Basic Information
| Provider Information | |||||||||
| NPI: | 1013984996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | SUMNER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.SC., M.SC., M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1928 RANDOLPH RD | ||||||||
| Address2: | SUITE 316 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043448846 | ||||||||
| FaxNumber: | 7043697999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1928 RANDOLPH RD | ||||||||
| Address2: | SUITE 316 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043448846 | ||||||||
| FaxNumber: | 7043697999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 15969 | NC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8952485 | 05 | NC | MEDICAID |