Provider Demographics
NPI:1407090335
Name:LA PORTE REGIONAL PHYSICIAN NETWORK, INC
Entity type:Organization
Organization Name:LA PORTE REGIONAL PHYSICIAN NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2485
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2489
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:SUITE 202
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-531-8908
Practice Address - Fax:219-548-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033345207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100165070FMedicaid
IN151020Medicare PIN