Basic Information
Provider Information | |||||||||
NPI: | 1437244597 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOGAN | ||||||||
FirstName: | ANN | ||||||||
MiddleName: | DRAYTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6100 W 96TH ST | ||||||||
Address2: | SUITE 125 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462786005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177151800 | ||||||||
FaxNumber: | 3177156200 | ||||||||
Practice Location | |||||||||
Address1: | 8244 EAST US 36 | ||||||||
Address2: |   | ||||||||
City: | AVON | ||||||||
State: | IN | ||||||||
PostalCode: | 46123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172723636 | ||||||||
FaxNumber: | 3172723646 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 07/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 01045617 | IN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 200161210 | 05 | IN |   | MEDICAID | 200259350 | 05 | IN |   | MEDICAID | BL5045174 | 01 | IN | DEA | OTHER | 01045617B | 01 | IN | CSR | OTHER |