Basic Information
| Provider Information | |||||||||
| NPI: | 1467531335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAPORTE OCCUPATIONAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 311 BOYD BLVD | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262664 | ||||||||
| FaxNumber: | 2193255435 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 BOYD BLVD | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262664 | ||||||||
| FaxNumber: | 2193255435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 08/07/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THORDARSON | ||||||||
| AuthorizedOfficialFirstName: | G | ||||||||
| AuthorizedOfficialMiddleName: | THOR | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2193262555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | 09-005006-1 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110269120 | 05 | IN | MEDICAID | 000000097783 | 01 | IN | ANTHEM | OTHER | 700339 | 05 | IN | MEDICAID | 100269110 | 05 | IN | MEDICAID |