Basic Information
| Provider Information | |||||||||
| NPI: | 1821211269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGUE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | CASE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62600 DEPT. 1721 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701622600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377061605 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1214 COOLIDGE BLVD. | ||||||||
| Address2: | SUITE C50 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372377927 | ||||||||
| FaxNumber: | 3372897935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 203343 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1810941 | 05 | LA | MEDICAID |