Basic Information
| Provider Information | |||||||||
| NPI: | 1093017196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL J. LOGAN MD, SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 15065 WESTOVER RD | ||||||||
| Address2: | |||||||||
| City: | ELM GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531221541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627861710 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16535 W BLUEMOUND RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530055906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627890909 | ||||||||
| FaxNumber: | 2628216180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2010 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOGAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JEFFREY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2627861710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 16418-20 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.