Healthcare Provider Details

I. General information

NPI: 1427373679
Provider Name (Legal Business Name): INDIANA UNIVERSITY HEALTH LAKESHORE SURGICARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 VILLAGE POINTE
CHESTERTON IN
46304-9689
US

IV. Provider business mailing address

3111 VILLAGE POINTE
CHESTERTON IN
46304-9689
US

V. Phone/Fax

Practice location:
  • Phone: 219-983-1401
  • Fax: 219-929-1408
Mailing address:
  • Phone: 219-983-1401
  • Fax: 219-929-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number13-011186-1
License Number StateIN

VIII. Authorized Official

Name: MR. GUDSTEINN T THORDARSON
Title or Position: PRESIDENT
Credential: N/A
Phone: 219-326-2555