1467622746 NPI number — LAPORTE REGIONAL PHYSICIAN NETWORK, INC.

Table of content: (NPI 1467622746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467622746 NPI number — LAPORTE REGIONAL PHYSICIAN NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAPORTE REGIONAL PHYSICIAN NETWORK, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467622746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAPORTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46352-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-326-2312
Provider Business Mailing Address Fax Number:
219-326-2584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S HEATON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOX
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46534-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-772-3187
Provider Business Practice Location Address Fax Number:
574-772-4843
Provider Enumeration Date:
03/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RAFALSKI
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
219-326-2347

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  01028450A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200171580 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01028450A . This is a "LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100225120 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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