Provider Demographics
NPI:1568656320
Name:LAPORTE OSTEOPATHIC FAMILY PRACTICE
Entity Type:Organization
Organization Name:LAPORTE OSTEOPATHIC FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:BERT
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-325-0155
Mailing Address - Street 1:125 EAST SHORE PARKWAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5672
Mailing Address - Country:US
Mailing Address - Phone:219-325-0155
Mailing Address - Fax:
Practice Address - Street 1:125 EAST SHORE PARKWAY
Practice Address - Street 2:SUITE D
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5677
Practice Address - Country:US
Practice Address - Phone:219-325-0155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100164980Medicaid
IN000000084179OtherANTHEM BLUE CROSS
IN15D0355679OtherCLIA
IN080025306OtherMEDICARE RAILROAD
IN100164980Medicaid
IN484980Medicare PIN