Basic Information
| Provider Information | |||||||||
| NPI: | 1619166253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | JUSTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DR | ||||||||
| Address2: | STE. 8502 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1814 WESTCHESTER DR | ||||||||
| Address2: | STE. 203 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022100 | ||||||||
| FaxNumber: | 3368022101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2007 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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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 | 2080P0205X | 50417 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 208000000X | 0101254581 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 50417 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | 0101254581 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 208000000X | 2007-01471 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.