Healthcare Provider Details

I. General information

NPI: 1831844539
Provider Name (Legal Business Name): HEALTHCARE PORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W 5TH AVE
GARY IN
46402-1808
US

IV. Provider business mailing address

804 MARYLAND ST
GARY IN
46402-2545
US

V. Phone/Fax

Practice location:
  • Phone: 219-248-4912
  • Fax:
Mailing address:
  • Phone: 219-248-4912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: CARYSIA ROBERTS
Title or Position: LAB COORDINATOR/DIRECTOR
Credential:
Phone: 219-248-4912