Logan Primary Care Service Corp.

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

036099669 Issued in IL

Legal business name

LOGAN PRIMARY CARE SERVICE CORP.

Practice address

502 W St Louis
West Frankfort, IL 62896

Phone

(618) 997-3400

Fax

(618) 932-3797

NPI assigned

Aug 19, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tara G Deaton

Title

Administrator

Phone

(618) 993-3300

Specialties & licenses 1

Addresses

Other identifiers 2

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Micah Oakley, PA-C

  • Physician Assistant
  • Herrin, IL
  • NPI 1912163189
  NPD (past)
• Elizabeth Ann Bohn, PA-C

  • Physician Assistant
  • Saint Louis, MO
  • NPI 1679721179
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155945600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1331856000000",
    "number": "1023123346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "405 RUSHING DRIVE",
            "city": "HERRIN",
            "state": "IL",
            "postal_code": "62948",
            "telephone_number": "618-993-3300",
            "fax_number": "618-997-6626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "502 W ST LOUIS",
            "city": "WEST FRANKFORT",
            "state": "IL",
            "postal_code": "62896",
            "telephone_number": "618-997-3400",
            "fax_number": "618-932-3797"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LOGAN PRIMARY CARE SERVICE CORP.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-19",
        "last_updated": "2012-03-16",
        "status": "A",
        "authorized_official_last_name": "DEATON",
        "authorized_official_first_name": "TARA",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "618-993-3300"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "IL",
            "license": "036099669",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "148969",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "10019630",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sydney Lawrence, LPC
• Stephen Douglas Leek, DC
• Rita Ann Lehker, LCPC
• Kenneth Lindsey
• Denise Lynn Loera, MS,LCPC
• Stephen Logue
• Brittany Lopez
• Sally Mandino
• Darci Kaye Mandrell, RPH
• Glenna Mann

• Rural Health Clinic/Center in West Frankfort, IL
• Providers in West Frankfort, IL by specialty
• Rural Health Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.