Provider Demographics
NPI:1043292576
Name:RELYEA-LOGAN, SARAH E (MD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:E
Last Name:RELYEA-LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:E
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:710 JOHNNIE DODDS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3045
Mailing Address - Country:US
Mailing Address - Phone:843-800-1303
Mailing Address - Fax:
Practice Address - Street 1:710 JOHNNIE DODDS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3045
Practice Address - Country:US
Practice Address - Phone:843-800-1303
Practice Address - Fax:888-316-7716
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39035207Q00000X
VA0101-236413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010093201Medicaid
VA010136768Medicaid
007061C40Medicare PIN
VA010136768Medicaid
005681C29Medicare PIN