Provider Demographics
NPI:1699767780
Name:LOGIE, KEITH W (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:LOGIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:6330 E 75TH ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2777
Mailing Address - Country:US
Mailing Address - Phone:317-594-6900
Mailing Address - Fax:317-594-6911
Practice Address - Street 1:10212 LANTERN RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9705
Practice Address - Country:US
Practice Address - Phone:317-841-5656
Practice Address - Fax:317-841-5751
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01031620207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN110031005OtherRAILROAD MEDICARE PIN
IN100323590Medicaid
IN100323590Medicaid
351348013OtherTAX ID NUMBER
D95339Medicare UPIN
INM400056819Medicare PIN