Basic Information
| Provider Information | |||||||||
| NPI: | 1912097197 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOGANSPORT FAMILY HEALTH CARE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SARA CATHERINE KIRKWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1201 MICHIGAN AVENUE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747224921 | ||||||||
| FaxNumber: | 5747390520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 MICHIGAN AVENUE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747224921 | ||||||||
| FaxNumber: | 5747390520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 01/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEUMANN | ||||||||
| AuthorizedOfficialFirstName: | CORY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF CORPORATION | ||||||||
| AuthorizedOfficialTelephone: | 5747224921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34004044A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.