Healthcare Provider Details

I. General information

NPI: 1043307978
Provider Name (Legal Business Name): NEIL WANGSTROM MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 DETROIT ST
LA PORTE IN
46350-2473
US

IV. Provider business mailing address

304 DETROIT ST
LA PORTE IN
46350-2473
US

V. Phone/Fax

Practice location:
  • Phone: 219-325-3770
  • Fax: 219-325-8181
Mailing address:
  • Phone: 219-325-3770
  • Fax: 219-325-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01038858
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002292A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001701A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001740A
License Number StateIN

VIII. Authorized Official

Name: MRS. ROBIN M HENRICH
Title or Position: PRACTICE MANAGER
Credential: CMPC
Phone: 219-325-3770