Basic Information
| Provider Information | |||||||||
| NPI: | 1679674956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARKVIEW LAGRANGE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5600 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737008 | ||||||||
| FaxNumber: | 2603737059 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 N TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467611325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604632143 | ||||||||
| FaxNumber: | 2604633190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RISSER | ||||||||
| AuthorizedOfficialFirstName: | STANTON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO - VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2603738403 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 282NC0060X | 06-005085-1 | IN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 000000361618 | 01 | IN | ANTHEM IDENTIFICATION # | OTHER | 404768667 | 05 | MI | MEDICAID | 1527449 | 01 | NCPDP | OTHER | 000000030598 | 01 | IN | MPLAN ID # | OTHER | 200524440A | 05 | IN | MEDICAID | 304768658 | 05 | MI | MEDICAID | 0000000361618 | 01 | IN | INDIANA COMP. ID # | OTHER | 18383 | 01 | IN | PHP IDENTIFICATION # | OTHER | 611159000 | 01 | IN | BLACK LUNG ID # | OTHER |