Provider Demographics
NPI:1952480154
Name:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Other - Org Name:INDIANA UNIVERSITY HEALTH LA PORTE VNA SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:G
Authorized Official - Middle Name:THOR
Authorized Official - Last Name:THORDARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-2555
Mailing Address - Street 1:901 SOUTH WOODLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-5672
Mailing Address - Country:US
Mailing Address - Phone:219-871-8100
Mailing Address - Fax:219-871-8113
Practice Address - Street 1:901 SOUTH WOODLAND AVENUE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-5672
Practice Address - Country:US
Practice Address - Phone:219-871-8100
Practice Address - Fax:219-871-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-006017-1251E00000X
IN11-005255-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200318440Medicaid
IN26-7760OtherMEDICARE PTAN - FLU SHOTS (MASTER ROSTER BILLING)
IN000000097786OtherANTHEM
IN157022Medicare Oscar/Certification
IN254310Medicare PIN