Provider Demographics
NPI:1487614152
Name:LOGAN VIEW PEDIATRICS
Entity type:Organization
Organization Name:LOGAN VIEW PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-593-0245
Mailing Address - Street 1:118 DOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 DOWELL AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2305
Practice Address - Country:US
Practice Address - Phone:937-593-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOGAN VIEW, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-25
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHL0893154Medicaid