Organization
LOGAN PRIMARY CARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TARA DEATON (ADMINISTRATOR)
(618) 993-3300
Entity
Organization
Contact information
Practice address
405 RUSHING DR, HERRIN, IL 62948-3730
(618) 993-3300
(618) 997-6626
Mailing address
405 RUSHING DR, HERRIN, IL 62948-3730
(618) 993-3300
(618) 997-6626
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
85003043
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
094621
HEALTH ALLIANCE
IL
01
—
10019630
BLUE CROSS BLUE SHIELD
IL
05
—
143870
—
IL
01
—
657869
HEALTHLINK
IL
01
—
P00166778
RAILROAD MEDICARE
IL
Enumeration date
10/11/2007
Last updated
10/11/2007
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