Healthcare Provider Details

I. General information

NPI: 1285870303
Provider Name (Legal Business Name): LAPORTE MEDICAL GROUP SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 I ST SUITE 1
LA PORTE IN
46350-5533
US

IV. Provider business mailing address

900 I ST SUITE 1
LA PORTE IN
46350-5533
US

V. Phone/Fax

Practice location:
  • Phone: 816-877-2005
  • Fax:
Mailing address:
  • Phone: 219-324-1670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. NEIL WANGSTROM
Title or Position: BOARD CHAIR
Credential:
Phone: 219-324-1670