Provider Demographics
NPI:1285604199
Name:BRIAN J. LOGUE MD. PC
Entity type:Organization
Organization Name:BRIAN J. LOGUE MD. PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-332-8765
Mailing Address - Street 1:2907 MCINTYRE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4209
Mailing Address - Country:US
Mailing Address - Phone:812-332-8765
Mailing Address - Fax:812-336-3425
Practice Address - Street 1:2907 S. MCINTIRE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4224
Practice Address - Country:US
Practice Address - Phone:812-332-8765
Practice Address - Fax:812-336-3425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200175020AMedicaid
IN000000098138OtherANTHEM BLUE SHIELD
INCD6715OtherTRAVELERS MEDICARE
IN1163510001Medicare NSC