Provider Demographics
NPI:1437153285
Name:MIDWEST EAR NOSE AND THROAT SURGERY, PSC
Entity Type:Organization
Organization Name:MIDWEST EAR NOSE AND THROAT SURGERY, PSC
Other - Org Name:MIDWEST OTOLARNGOLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-473-2060
Mailing Address - Street 1:1401 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8014
Mailing Address - Country:US
Mailing Address - Phone:812-473-2060
Mailing Address - Fax:812-473-0763
Practice Address - Street 1:1401 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-8014
Practice Address - Country:US
Practice Address - Phone:812-473-2060
Practice Address - Fax:812-473-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200069270AMedicaid
KY65937542Medicaid
IN200069270DMedicaid
INP00076697Medicare PIN
KY65937542Medicaid
INP00280947Medicare PIN
KY040003023Medicare PIN
IN200069270DMedicaid
INP00153580Medicare PIN
KY040013796Medicare PIN
KY040009489Medicare PIN
INP00280944Medicare PIN
KY8456Medicare PIN