Provider Demographics
NPI:1396755054
Name:LOGAN, JOSEPH WILLIS SR (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WILLIS
Last Name:LOGAN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3860
Mailing Address - Country:US
Mailing Address - Phone:864-725-4780
Mailing Address - Fax:864-725-4778
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4780
Practice Address - Fax:864-725-4778
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8327207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC083279Medicaid
SC083279Medicaid
SCD906081124Medicare PIN