Healthcare Provider Details

I. General information

NPI: 1295498947
Provider Name (Legal Business Name): NORTHSHORE HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 3RD CT SE
DEMOTTE IN
46310-7400
US

IV. Provider business mailing address

PO BOX 1430
PORTAGE IN
46368-9230
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax:
Mailing address:
  • Phone: 219-763-8112
  • Fax: 219-764-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAVID HALL
Title or Position: CEO
Credential:
Phone: 219-763-8112