Healthcare Provider Details

I. General information

NPI: 1093178477
Provider Name (Legal Business Name): RYAN LOGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8040 CLEARVISTA PKWY STE 440
INDIANAPOLIS IN
46256-4673
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5510
  • Fax:
Mailing address:
  • Phone: 317-621-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01087732A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: