Basic Information
| Provider Information | |||||||||
| NPI: | 1245263631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOGAN MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOGAN CARE FOR WOMEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1623 NASHVILLE ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422768889 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1623 NASHVILLE ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422768889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.