Provider Demographics
NPI:1578674495
Name:LAPORTE REGIONAL PHYSICIAN NETORK
Entity Type:Organization
Organization Name:LAPORTE REGIONAL PHYSICIAN NETORK
Other - Org Name:JOHNSON ROAD INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2485
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
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 1:7002 W JOHNSON RD
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-8289
Practice Address - Country:US
Practice Address - Phone:219-325-0604
Practice Address - Fax:219-879-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100165070BMedicaid
IN151020Medicare PIN
IN489140Medicare PIN