Provider Demographics
NPI:1679674956
Name:COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC
Entity Type:Organization
Organization Name:COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC
Other - Org Name:PARKVIEW LAGRANGE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CFO - VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-373-8403
Mailing Address - Street 1:PO BOX 5600
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46895-5600
Mailing Address - Country:US
Mailing Address - Phone:260-373-7008
Mailing Address - Fax:260-373-7059
Practice Address - Street 1:207 N TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1325
Practice Address - Country:US
Practice Address - Phone:260-463-2143
Practice Address - Fax:260-463-3190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-26
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-005085-1282NC0060X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000361618OtherANTHEM IDENTIFICATION #
MI404768667Medicaid
1527449OtherNCPDP
IN000000030598OtherMPLAN ID #
IN200524440AMedicaid
MI304768658Medicaid
IN0000000361618OtherINDIANA COMP. ID #
IN18383OtherPHP IDENTIFICATION #
IN611159000OtherBLACK LUNG ID #
IN0000000361618OtherINDIANA COMP. ID #
IN0000000361618OtherINDIANA COMP. ID #