Basic Information
| Provider Information | |||||||||
| NPI: | 1891031191 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOGAN PHYSICIAN PRACTICE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AUBURN COMMUNITY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 SUGAR MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422065352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705425500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 128 SUGAR MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422065352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705425500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2012 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOGAN PHYSICIAN PRACTICE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.