Basic Information
| Provider Information | |||||||||
| NPI: | 1427054873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SOUTHBOROUGH DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612018 | ||||||||
| FaxNumber: | 2076612033 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 UNION ST | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 048412739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077014400 | ||||||||
| FaxNumber: | 2077014487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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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 | 208000000X | 012617 | ME | N | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | MD12617 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084A0401X | MD12617 | ME | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 255750099 | 05 | ME | MEDICAID | 047853 | 01 | ME | ANTHEM STAR NUMBER | OTHER |