Basic Information
| Provider Information | |||||||||
| NPI: | 1285991885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST INDIANA NEPHROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2711 LEONARD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463837121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194626001 | ||||||||
| FaxNumber: | 2194626060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2711 LEONARD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463837121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194626001 | ||||||||
| FaxNumber: | 2194626060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | PAMPALONE | ||||||||
| AuthorizedOfficialFirstName: | AJ | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2198362022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 201062390 | 05 | IN | MEDICAID |