Provider Demographics
NPI:1184703704
Name:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Entity type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1007 LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-0250
Mailing Address - Country:US
Mailing Address - Phone:219-326-1234
Mailing Address - Fax:219-325-5403
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46352-0250
Practice Address - Country:US
Practice Address - Phone:219-326-1234
Practice Address - Fax:219-325-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2013-09-16
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-07
Provider Licenses
StateLicense IDTaxonomies
IN09-005006-1273Y00000X
IN11-005006-1273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100269110Medicaid
IN000000097783OtherANTHEM
IN200714310Medicaid
IN700339Medicaid
IN100269120Medicaid
IN15T006Medicare Oscar/Certification
IN700339Medicaid