Provider Demographics
NPI:1508854431
Name:LOGAN, THOMAS BROOKS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BROOKS
Last Name:LOGAN
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 1:1020 PROFESSIONAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-8009
Mailing Address - Country:US
Mailing Address - Phone:812-473-2060
Mailing Address - Fax:812-473-0763
Practice Address - Street 1:800 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2709
Practice Address - Country:US
Practice Address - Phone:812-499-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029120A207Y00000X
KY14807207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000181609OtherANTHEM
IN110013OtherHEALTHLINK
IN100246610AMedicaid
IN064946OtherHEALTH ALLIANCE
KY000000181609OtherANTHEM
KY64148075Medicaid
IN064946OtherHEALTH ALLIANCE
INC25866Medicare UPIN
KY000000181609OtherANTHEM
IN637090AMedicare ID - Type Unspecified
IN100246610AMedicaid