Provider Demographics
NPI:1467622746
Name:LAPORTE REGIONAL PHYSICIAN NETWORK, INC.
Entity Type:Organization
Organization Name:LAPORTE REGIONAL PHYSICIAN NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2347
Mailing Address - Street 1:P.O. BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:1901 S HEATON
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2325
Practice Address - Country:US
Practice Address - Phone:574-772-3187
Practice Address - Fax:574-772-4843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028450A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200171580Medicaid
IN01028450AOtherLICENSE
IN100225120Medicaid
INM400023747Medicare PIN
INE15281Medicare UPIN