Provider Demographics
NPI:1043307978
Name:NEIL WANGSTROM MD PC
Entity Type:Organization
Organization Name:NEIL WANGSTROM MD PC
Other - Org Name:NORTHWEST INDIANA ENT ASSOICATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENRICH
Authorized Official - Suffix:
Authorized Official - Credentials:CMPC
Authorized Official - Phone:219-325-3770
Mailing Address - Street 1:304 DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-2473
Mailing Address - Country:US
Mailing Address - Phone:219-325-3770
Mailing Address - Fax:219-325-8181
Practice Address - Street 1:304 DETROIT ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2473
Practice Address - Country:US
Practice Address - Phone:219-325-3770
Practice Address - Fax:219-325-8181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038858207Y00000X
IN23002292A231H00000X
IN71001701A363L00000X
IN71001740A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100165330AMedicaid
IN000000105404OtherANTHEM
IN200245050AMedicaid
IN200482190Medicaid
IN100165330Medicaid
IN224040Medicare PIN
IN100165330Medicaid
IN224040CMedicare PIN
INQ60281Medicare UPIN
IN200245050AMedicaid