Provider Demographics
NPI:1497723076
Name:LOGAN, KELSEY (MD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 10001
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4366
Mailing Address - Fax:513-636-0516
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 10001
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4366
Practice Address - Fax:513-636-0516
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.093069208000000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2932509Medicaid
OH4257342Medicare PIN
OH2932509Medicaid
I23541Medicare UPIN