Provider Demographics
NPI:1871550152
Name:LOGAN, MICHAEL JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEFFREY
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15065 WESTOVER ROAD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1541
Mailing Address - Country:US
Mailing Address - Phone:262-786-1710
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5906
Practice Address - Country:US
Practice Address - Phone:262-789-0909
Practice Address - Fax:262-821-6180
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31226500Medicaid
B54653Medicare UPIN
WI68456Medicare ID - Type Unspecified