Healthcare Provider Details

I. General information

NPI: 1760593776
Provider Name (Legal Business Name): INDIANA UNIVERSITY HEALTH LA PORTE PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 LINCOLNWAY
LA PORTE IN
46350-3201
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-2489
  • Fax: 219-326-2584
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIAN DONNELLY
Title or Position: VP OF STRATEGY & AMBULATORY SERVICE
Credential:
Phone: 219-325-4682