Provider Demographics
| NPI: | 1861636664 |
|---|---|
| Name: | NORTHSHORE HEALTH CENTERS, INC. |
| Entity Type: | Organization |
| Organization Name: | NORTHSHORE HEALTH CENTERS, INC. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DAVID |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | HALL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 219-763-8112 |
| Mailing Address - Street 1: | PO BOX 1430 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | PORTAGE |
| Mailing Address - State: | IN |
| Mailing Address - Zip Code: | 46368-9230 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 219-763-8112 |
| Mailing Address - Fax: | 219-764-5380 |
| Practice Address - Street 1: | 2490 CENTRAL AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | LAKE STATION |
| Practice Address - State: | IN |
| Practice Address - Zip Code: | 46405-2122 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 219-763-8112 |
| Practice Address - Fax: | 219-962-1580 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2009-04-23 |
| Last Update Date: | 2020-11-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LW0102X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | Group - Multi-Specialty |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IN | 151846 | Other | MEDICARE PART A PTAN |
| IN | 191360 | Other | MEDICARE PART B PTAN |
| IN | 200331170D | Medicaid | |
| IN | 191360 | Other | MEDICARE PART B PTAN |
