1750517603 NPI number — LA PORTE REGIONAL PHYSICIAN NETWORK, INC.

Table of content: (NPI 1750517603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750517603 NPI number — LA PORTE REGIONAL PHYSICIAN NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA PORTE 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:
6
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:
1750517603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PORTE
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:
219-326-2489
Provider Business Mailing Address Fax Number:
219-326-2584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
156 FLYNN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46391-9491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-785-7021
Provider Business Practice Location Address Fax Number:
219-785-7159
Provider Enumeration Date:
06/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VOLK
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
219-326-2485

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100165070J , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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