Healthcare Provider Details

I. General information

NPI: 1699767780
Provider Name (Legal Business Name): KEITH W LOGIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10212 LANTERN RD
FISHERS IN
46037-9705
US

IV. Provider business mailing address

6330 E 75TH ST SUITE 140
INDIANAPOLIS IN
46250-2777
US

V. Phone/Fax

Practice location:
  • Phone: 317-841-5656
  • Fax: 317-841-5751
Mailing address:
  • Phone: 317-594-6900
  • Fax: 317-594-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01031620
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: