Provider Demographics
NPI:1831399278
Name:P C LOGAN MD INC
Entity type:Organization
Organization Name:P C LOGAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:CLIFFORD
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-359-5357
Mailing Address - Street 1:1910 N ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-5128
Mailing Address - Country:US
Mailing Address - Phone:317-359-5357
Mailing Address - Fax:317-359-5358
Practice Address - Street 1:1910 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-5128
Practice Address - Country:US
Practice Address - Phone:317-359-5357
Practice Address - Fax:317-359-5358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020481A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082565OtherANTHEM BLUE CROSS & BLUE
IN100055560AMedicaid
IN072068448OtherRAILROAD MEDICARE
IND67805Medicare UPIN
IN100055560AMedicaid