Basic Information
| Provider Information | |||||||||
| NPI: | 1467911339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINNEY | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | PETE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 COLDBROOK ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088709758 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 05 | NC | MEDICAID |