Healthcare Provider Details

I. General information

NPI: 1508854431
Provider Name (Legal Business Name): THOMAS BROOKS LOGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N ELM ST
HENDERSON KY
42420-2709
US

IV. Provider business mailing address

1020 PROFESSIONAL BOULEVARD
EVANSVILLE IN
47714-8009
US

V. Phone/Fax

Practice location:
  • Phone: 812-499-9948
  • Fax:
Mailing address:
  • Phone: 812-473-2060
  • Fax: 812-473-0763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01029120A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number14807
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: