Basic Information
| Provider Information | |||||||||
| NPI: | 1689965204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGHAN | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13500 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | BOONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954159133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078953477 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1515 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974249700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417675200 | ||||||||
| FaxNumber: | 5417675200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2011 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD181244 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1689965204 | 05 | CA | MEDICAID |