Basic Information
Provider Information | |||||||||
NPI: | 1558517144 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOGAN | ||||||||
FirstName: | LATANIA | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., MSPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROYLS | ||||||||
OtherFirstName: | LATANIA | ||||||||
OtherMiddleName: | K. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1725 W HARRISON ST | ||||||||
Address2: | STE 710 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606123841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129426396 | ||||||||
FaxNumber: | 3129424168 | ||||||||
Practice Location | |||||||||
Address1: | 1400 TULLIE RD NE | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303292309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047855437 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2008 | ||||||||
LastUpdateDate: | 06/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036-113313 | IL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0208X | 036-113313 | IL | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 2080P0208X | 92099 | GA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
ID | Type | State | Issuer | Description | 036-113313 | 01 | IL | STATE LICENSE NUMBER | OTHER | 336-074676 | 01 | IL | STATE LICENSE, CONTROLLED SUBSTANCE | OTHER | 92099 | 01 | GA | STATE LICENSE NUMBER | OTHER |