Provider Demographics
NPI:1912953043
Name:NORTHERN INDIANA ONCOLOGY CENTER OF PORTER MEMORIAL HOSPITAL LLC
Entity type:Organization
Organization Name:NORTHERN INDIANA ONCOLOGY CENTER OF PORTER MEMORIAL HOSPITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KOPPOLU
Authorized Official - Middle Name:P
Authorized Official - Last Name:SARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-462-8246
Mailing Address - Street 1:DEPT 6064
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-6064
Mailing Address - Country:US
Mailing Address - Phone:219-462-8249
Mailing Address - Fax:219-462-7902
Practice Address - Street 1:54 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-462-8249
Practice Address - Fax:219-462-7902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200009380AMedicaid
IN658870Medicare PIN