Provider Demographics
NPI:1689712093
Name:INTERNAL MEDICINE CENTER OF NW INDIANA, PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CENTER OF NW INDIANA, PC
Other - Org Name:ADVANCED REHABILITATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:CRTT
Authorized Official - Phone:219-985-1112
Mailing Address - Street 1:5800 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2601
Mailing Address - Country:US
Mailing Address - Phone:219-985-1112
Mailing Address - Fax:219-985-1150
Practice Address - Street 1:5800 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2601
Practice Address - Country:US
Practice Address - Phone:219-985-1112
Practice Address - Fax:219-985-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007981A225100000X
IN30001586A227800000X
IN30001325A227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200121630AMedicaid
IN200121630AMedicaid