Provider Demographics
NPI:1467531335
Name:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Other - Org Name:LAPORTE OCCUPATIONAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:THOR
Authorized Official - Last Name:THORDARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2555
Mailing Address - Street 1:311 BOYD BLVD
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3965
Mailing Address - Country:US
Mailing Address - Phone:219-326-2664
Mailing Address - Fax:219-325-5435
Practice Address - Street 1:311 BOYD BLVD
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3965
Practice Address - Country:US
Practice Address - Phone:219-326-2664
Practice Address - Fax:219-325-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2013-09-16
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-07
Provider Licenses
StateLicense IDTaxonomies
IN09-005006-1261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN110269120Medicaid
IN000000097783OtherANTHEM
IN700339Medicaid
IN100269110Medicaid
IN110269120Medicaid
IN000000097783OtherANTHEM