Provider Demographics
NPI:1467450767
Name:LOGUE, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:LOGUE
Suffix:
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 1:2907 MCINTYRE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4209
Mailing Address - Country:US
Mailing Address - Phone:812-332-8765
Mailing Address - Fax:812-336-3425
Practice Address - Street 1:2907 S MCINTIRE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4224
Practice Address - Country:US
Practice Address - Phone:812-332-8765
Practice Address - Fax:812-336-3425
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037620A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100167090Medicaid
IN546100Medicare ID - Type Unspecified
E10481Medicare UPIN