Healthcare Provider Details

I. General information

NPI: 1114038908
Provider Name (Legal Business Name): LAPORTE REGIONAL PHYSICIAN NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 STATE ST SUITE 1B
LA PORTE IN
46350-3185
US

IV. Provider business mailing address

1100 LINCOLNWAY
LA PORTE IN
46350-3289
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-0000
  • Fax: 219-326-0040
Mailing address:
  • Phone: 219-326-2489
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY T MCDERMOTT
Title or Position: VICE PRESIDENT, COO
Credential:
Phone: 219-326-2489