Organization
LOGAN PRIMARY CARE SERVICE CORP.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TARA G DEATON (ADMINISTRATOR)
(618) 993-3300
Entity
Organization
Contact information
Practice address
502 W ST LOUIS, WEST FRANKFORT, IL 62896
(618) 997-3400
(618) 932-3797
Mailing address
405 RUSHING DRIVE, HERRIN, IL 62948
(618) 993-3300
(618) 997-6626
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
036099669
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10019630
BLUE CROSS BLUE SHIELD
IL
05
—
148969
—
IL
Enumeration date
08/19/2006
Last updated
03/16/2012
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