Provider Demographics
NPI:1083810253
Name:LAKE PARK CLINIC, P.C.
Entity Type:Organization
Organization Name:LAKE PARK CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-942-1422
Mailing Address - Street 1:1356 S LAKE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-5964
Mailing Address - Country:US
Mailing Address - Phone:219-942-8518
Mailing Address - Fax:219-947-2751
Practice Address - Street 1:1356 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5964
Practice Address - Country:US
Practice Address - Phone:219-942-8518
Practice Address - Fax:219-947-2751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000086604OtherBLUE CROSS BLUE SHIELD
IN000000550461OtherANTHEM
IN100159850AMedicaid
IN47134001Medicare PIN
IN000000086604OtherBLUE CROSS BLUE SHIELD
IN100159850AMedicaid
IN471340AMedicare PIN