Provider Demographics
NPI:1043212988
Name:LOGAN RADIOLOGY GROUP LLC
Entity type:Organization
Organization Name:LOGAN RADIOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-296-2113
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1108
Mailing Address - Country:US
Mailing Address - Phone:801-296-2113
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:281-980-1430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119042300Medicaid
ID002979600Medicaid
WY119042300Medicaid
UT000055469Medicare PIN
UT=========000Medicaid
UTCD4416Medicare PIN
ID1375133Medicare PIN