Provider Demographics
NPI:1134191463
Name:LOGAN, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:7804 FAIRVIEW RD STE C
Mailing Address - Street 2:PMB 302
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4999
Mailing Address - Country:US
Mailing Address - Phone:704-541-1213
Mailing Address - Fax:704-541-4210
Practice Address - Street 1:2701 COLTSGATE RD
Practice Address - Street 2:#105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3534
Practice Address - Country:US
Practice Address - Phone:704-541-1213
Practice Address - Fax:704-541-4210
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-08-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC98006122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891139VMedicaid
SCN00612Medicaid
SCN00612Medicaid
NC891139VMedicaid