Provider Demographics
NPI:1659445286
Name:PORTER COUNTY PHYSICAL MED REHAB
Entity Type:Organization
Organization Name:PORTER COUNTY PHYSICAL MED REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INS COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-548-3828
Mailing Address - Street 1:2600 N ROOSEVELT ROAD
Mailing Address - Street 2:STE 200 3
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-0970
Mailing Address - Country:US
Mailing Address - Phone:219-548-3828
Mailing Address - Fax:219-548-3803
Practice Address - Street 1:2600 N ROOSEVELT ROAD
Practice Address - Street 2:STE 200 3
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-0970
Practice Address - Country:US
Practice Address - Phone:219-548-3828
Practice Address - Fax:219-548-3803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003279A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000356528OtherGROUP NUMBER BCBS
IN154529Medicare ID - Type UnspecifiedGROUP NUMBER PART A