Provider Demographics
NPI:1851492177
Name:PORTER COUNTY INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:PORTER COUNTY INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-464-3941
Mailing Address - Street 1:3705 QUAIL COVEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2278
Mailing Address - Country:US
Mailing Address - Phone:219-464-3941
Mailing Address - Fax:219-464-3941
Practice Address - Street 1:3705 QUAIL COVEY DRIVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2278
Practice Address - Country:US
Practice Address - Phone:219-464-3941
Practice Address - Fax:219-464-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200019300AMedicaid
IN200019300AMedicaid