Provider Demographics
NPI:1225118474
Name:WOODLAND HEALTHCARE LLC
Entity Type:Organization
Organization Name:WOODLAND HEALTHCARE LLC
Other - Org Name:WOODLAND HEALTHCARE SURGICENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:G
Authorized Official - Middle Name:THOR
Authorized Official - Last Name:THORDARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-877-2222
Mailing Address - Street 1:8865 W 400 N STE 100
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9223
Mailing Address - Country:US
Mailing Address - Phone:219-877-2222
Mailing Address - Fax:219-877-2220
Practice Address - Street 1:8865 W 400 N STE 100
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9223
Practice Address - Country:US
Practice Address - Phone:219-877-2222
Practice Address - Fax:219-877-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherTAX ID
INZHO60Medicare UPIN
INZH0680Medicare ID - Type UnspecifiedMEDICARE PROVIDER #