Provider Demographics
NPI:1124050687
Name:LOGHRY, MARY CAROLINE (MD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CAROLINE
Last Name:LOGHRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:CAROLINE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:150 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2368
Mailing Address - Country:US
Mailing Address - Phone:931-528-1485
Mailing Address - Fax:931-526-4233
Practice Address - Street 1:150 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2368
Practice Address - Country:US
Practice Address - Phone:931-528-1485
Practice Address - Fax:931-526-4233
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41159208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1538173471OtherCOOKEVILLE PEDIATRIC ASSOCIATES NPI
TN4130317OtherBCBS
TN1517710Medicaid
TN5440812Medicaid