Provider Demographics
NPI:1114038908
Name:LAPORTE REGIONAL PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:LAPORTE REGIONAL PHYSICIAN NETWORK
Other - Org Name:LAKELAND PSYCHIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, COO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2489
Mailing Address - Street 1:1100 LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3289
Mailing Address - Country:US
Mailing Address - Phone:219-326-2489
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:1300 STATE ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3185
Practice Address - Country:US
Practice Address - Phone:219-326-0000
Practice Address - Fax:219-326-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151020Medicare PIN