MEDICARE: P C LOGAN MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	01020481A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	072068448	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000082565	OTHER	IN	ANTHEM BLUE CROSS & BLUE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831399278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P C LOGAN MD INC

Provider Business Mailing Address
First Line	:	1910 N ARLINGTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-5128
Country	:	US
Telephone Number	:	317-359-5357
Fax Number	:	317-359-5358

Provider Business Practice Location Address
First Line	:	1910 N ARLINGTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-5128
Country	:	US
Telephone Number	:	317-359-5357
Fax Number	:	317-359-5358

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. PATRICK CLIFFORD LOGAN
Credential	:	MD
Telephone Number	:	317-359-5357

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	07/24/2007

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Directions to “P C LOGAN MD INC ” Practice Location

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