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Organization
LOGAN PRIMARY CARE SERVICE CORPORATION
Active
Organization
LOGAN PRIMARY CARE SERVICE CORPORATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TARA G DEATON (ADMINISTRATOR)
(618) 993-3300
Entity
Organization
Contact information
Practice address
405 RUSHING DRIVE, HERRIN, IL 62948
(618) 993-3300
(618) 997-6626
Mailing address
405 RUSHING DRIVE, HERRIN, IL 62948
(618) 993-3300
(618) 997-6626
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036099669
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10019630
BLUE CROSS BLUE SHIELD
IL
05
—
143870
—
IL
01
—
14D0436594
CLIA
—
01
—
14D0666068
CLIA
—
01
—
14D0963522
CLIA
—
01
—
14D1041426
CLIA
—
Enumeration date
08/24/2006
Last updated
11/29/2007
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