Provider Demographics
NPI:1568487981
Name:LOGANATHAN, SRI (MD)
Entity Type:Individual
Prefix:
First Name:SRI
Middle Name:
Last Name:LOGANATHAN
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:PO BOX 17572
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1572
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:411 W RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2938
Practice Address - Country:US
Practice Address - Phone:804-452-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027071207P00000X
DC8129207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010055890Medicaid
VA1568487981Medicaid
VA010002401Medicaid
VA003085V67Medicare PIN
VAVV0910AMedicare PIN
VA1568487981Medicaid
VA00197V01Medicare PIN