Provider Demographics
NPI:1942466354
Name:LA PORTE REGIONAL PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:LA PORTE REGIONAL PHYSICIAN NETWORK
Other - Org Name:DALPHOND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2485
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:
Practice Address - Street 1:108 W STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH JUDSON
Practice Address - State:IN
Practice Address - Zip Code:46366-1320
Practice Address - Country:US
Practice Address - Phone:574-896-5533
Practice Address - Fax:574-896-5218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN760420OtherMEDICARE
IN100165070EMedicaid
IN760420OtherMEDICARE