Provider Demographics
NPI:1760593776
Name:INDIANA UNIVERSITY HEALTH LA PORTE PHYSICIANS INC
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH LA PORTE PHYSICIANS INC
Other - Org Name:LA PORTE REGIONAL PHYSICIAN NETWORK INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP OF STRATEGY & AMBULATORY SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-325-4682
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 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3201
Practice Address - Country:US
Practice Address - Phone:219-326-2489
Practice Address - Fax:219-326-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200255890Medicaid
IN100165070Medicaid
IN200988350Medicaid
IN153857Medicare Oscar/Certification
IN0478230001Medicare NSC
IN151020Medicare PIN