Provider Demographics
NPI:1972694669
Name:LAKE-PORTER CARDIOVASCULAR PC
Entity Type:Organization
Organization Name:LAKE-PORTER CARDIOVASCULAR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-477-4452
Mailing Address - Street 1:2000 ROOSEVELT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2801
Mailing Address - Country:US
Mailing Address - Phone:219-462-1619
Mailing Address - Fax:219-548-0867
Practice Address - Street 1:2000 ROOSEVELT RD STE 101
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2801
Practice Address - Country:US
Practice Address - Phone:219-462-1619
Practice Address - Fax:219-548-0867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000940A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100141870AMedicaid
387190Medicare PIN