Provider Demographics
NPI:1699704304
Name:NORTHWEST INDIANA ONCOLOGY PC
Entity type:Organization
Organization Name:NORTHWEST INDIANA ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-363-2134
Mailing Address - Street 1:8865 W 400 N
Mailing Address - Street 2:SUITE 165
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9222
Mailing Address - Country:US
Mailing Address - Phone:219-872-2536
Mailing Address - Fax:219-872-2533
Practice Address - Street 1:8865 W 400 N
Practice Address - Street 2:SUITE 165
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9222
Practice Address - Country:US
Practice Address - Phone:219-872-2536
Practice Address - Fax:219-872-2533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040872207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN487360Medicare ID - Type Unspecified
INF01651Medicare UPIN