NPIMap

Organization Active NPI

Logan Pediatrics, Inc

  • Rural Health Clinic/Center
  • Logan, WV
National Provider Identifier
1396409173
Registry record updated Oct 27, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LOGAN PEDIATRICS, INC
Practice address
300 Prosperity Lane
Suite 100
Logan, WV 25601
Phone
(304) 831-0073
Fax
(304) 831-0076
NPI assigned
Oct 27, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 27, 2021

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

Authorized official

Name
Mr. Okpani Martin Nnachi, MD
Title
Medical Director
Phone
(304) 831-0073

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

300 Prosperity Lane
Suite 100
Logan, WV 25601

Mailing address

300 Prosperity Lane
Suite 100
Logan, WV 25601
Phone (304) 831-0073

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220106002141 WV Part A Provider - Rural Health Clinic 5597835371 Practice locations: Logan, WV

Rural health clinic certification: CCN 518900

Legal name
LOGAN PEDIATRICS, INC
Doing business as
LOGAN PEDIATRICS
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 13, 2023
Last certification
Feb 13, 2023
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Mar 3, 2008 in WV
Enrollment address
300 Prosperity LN
Ste 100
Logan, WV 25601-3743

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
51D1048463Logan Pediatrics Inc300 Prosperity Lane # 100, Logan, WV 25601Certificate of waiverDec 1, 2027

National Provider Directory

National Provider Directory
Tax ID family
Logan Pediatrics Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Locations

300 Prosperity Ln
Ste 100
Logan, WV 25601
Phone (304) 831-0073

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Okpani Martin Nnachi Individual 5% Or Greater Direct Ownership Interest Mar 3, 2008 100%
Corporate DirectorOwner/Medical Director Mar 3, 2008 100%
W-2 Managing EmployeeOwner/Medical Director Mar 3, 2008 100%

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": "1635292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635292800000",
    "number": "1396409173",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 PROSPERITY LANE",
            "address_2": "SUITE 100",
            "city": "LOGAN",
            "state": "WV",
            "postal_code": "25601",
            "telephone_number": "304-831-0073",
            "fax_number": "304-831-0076"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 PROSPERITY LANE",
            "address_2": "SUITE 100",
            "city": "LOGAN",
            "state": "WV",
            "postal_code": "25601",
            "telephone_number": "304-831-0073",
            "fax_number": "304-831-0076"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LOGAN PEDIATRICS, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-27",
        "last_updated": "2021-10-27",
        "certification_date": "2021-10-27",
        "status": "A",
        "authorized_official_last_name": "NNACHI",
        "authorized_official_first_name": "OKPANI",
        "authorized_official_middle_name": "MARTIN",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "304-831-0073",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Logan, WV

Sources for this page

Verify at the official NPI Registry.