Basic Information
| Provider Information | |||||||||
| NPI: | 1194999888 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESHORE BONE & JOINT INSTITUTE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 GATEWAY BLVD N | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463049658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | 2199215303 | ||||||||
| Practice Location | |||||||||
| Address1: | 3777 FRONTAGE RD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463607695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | 2199215303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | THOMA | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE- PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2199211444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.