Basic Information
| Provider Information | |||||||||
| NPI: | 1407090335 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA PORTE REGIONAL PHYSICIAN NETWORK, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1690 | ||||||||
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| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463521690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262489 | ||||||||
| FaxNumber: | 2193262584 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 ROOSEVELT RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463832800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195318908 | ||||||||
| FaxNumber: | 2195480108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | VOLK | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2193262485 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 01033345 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100165070F | 05 | IN | MEDICAID |