Provider Demographics
NPI:1093178477
Name:LOGUE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LOGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7547
Mailing Address - Fax:
Practice Address - Street 1:7250 CLEARVISTA DR STE 355
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5609
Practice Address - Country:US
Practice Address - Phone:317-621-5676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
IN01087732A207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00369282OtherRAILROAD MEDICARE