MEDICARE: INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	06-006017-1	IN
2	251G00000X	Community Based Hospice Care Agency	11-006017-1	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000097786	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1447336938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL INC

Provider Business Mailing Address
First Line	:	901 SOUTH WOODLAND AVE
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-5672
Country	:	US
Telephone Number	:	219-871-8100
Fax Number	:	219-871-8113

Provider Business Practice Location Address
First Line	:	901 SOUTH WOODLAND AVE
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-5672
Country	:	US
Telephone Number	:	219-871-8100
Fax Number	:	219-871-8113

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. G THOR THORDARSON
Credential	:
Telephone Number	:	219-326-2555

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	09/16/2013

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