Provider Demographics
NPI:1659456580
Name:INDIANA UNVERSITY HEALTH LA PORTE HOSPITAL INC
Entity Type:Organization
Organization Name:INDIANA UNVERSITY HEALTH LA PORTE HOSPITAL INC
Other - Org Name:LA PORTE REGIONAL HEALTH SYSTEM INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
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:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-0250
Mailing Address - Country:US
Mailing Address - Phone:219-326-1234
Mailing Address - Fax:219-326-2387
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3290
Practice Address - Country:US
Practice Address - Phone:219-326-1234
Practice Address - Fax:219-326-2387
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09-005006-1273R00000X
IN11-005006-1273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN700339Medicaid
IN100269120Medicaid
IN100269110Medicaid
IN000000097783OtherANTHEM
IN940640Medicare PIN
IN15S006Medicare Oscar/Certification