Provider Demographics
NPI:1114257300
Name:NORTHSHORE HEALTH CENTERS INC
Entity type:Organization
Organization Name:NORTHSHORE HEALTH CENTERS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-763-8112
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:8555 TAFT ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6123
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151861OtherMEDICARE PTAN
IN200331170Medicaid
IN191360OtherMEDICARE PART B PTAN