Basic Information
| Provider Information | |||||||||
| NPI: | 1750517603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA PORTE REGIONAL PHYSICIAN NETWORK, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTVILLE FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1690 | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463521690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262489 | ||||||||
| FaxNumber: | 2193262584 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 FLYNN ROAD | ||||||||
| Address2: | |||||||||
| City: | WESTVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463919491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197857021 | ||||||||
| FaxNumber: | 2197857159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2009 | ||||||||
| LastUpdateDate: | 06/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | VOLK | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2193262485 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100165070J | 05 | IN | MEDICAID |