NPIMap

Organization Active NPI

Logan Primary Care

  • Physician Assistant
  • Herrin, IL
National Provider Identifier
1194913541
Registry record updated Oct 11, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
85003043 Issued in IL
Legal business name
LOGAN PRIMARY CARE
Practice address
405 Rushing Dr
Herrin, IL 62948-3730
Phone
(618) 993-3300
Fax
(618) 997-6626
NPI assigned
Oct 11, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 11, 2007

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

Authorized official

Name
Mrs. Tara Deaton
Title
Administrator
Phone
(618) 993-3300

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X 85003043 IL Primary

Addresses

Primary practice location

405 Rushing Dr
Herrin, IL 62948-3730

Mailing address

405 Rushing Dr
Herrin, IL 62948-3730
Phone (618) 993-3300

Other identifiers 5

IdentifierTypeStateIssuer
P00166778OtherILRAILROAD MEDICARE
094621OtherILHEALTH ALLIANCE
143870MedicaidIL
10019630OtherILBLUE CROSS BLUE SHIELD
657869OtherILHEALTHLINK

National Provider Directory

National Provider Directory
Tax ID family
Logan Primary Care5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 2

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

NPI Registry JSON

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

{
    "created_epoch": "1192060800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1192060800000",
    "number": "1194913541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "405 RUSHING DR",
            "city": "HERRIN",
            "state": "IL",
            "postal_code": "629483730",
            "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": "405 RUSHING DR",
            "city": "HERRIN",
            "state": "IL",
            "postal_code": "629483730",
            "telephone_number": "618-993-3300",
            "fax_number": "618-997-6626"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LOGAN PRIMARY CARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-11",
        "last_updated": "2007-10-11",
        "status": "A",
        "authorized_official_last_name": "DEATON",
        "authorized_official_first_name": "TARA",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "618-993-3300",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "85003043",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00166778",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH ALLIANCE",
            "identifier": "094621",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "143870",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "10019630",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHLINK",
            "identifier": "657869",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Herrin, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.