Healthcare Provider Details

I. General information

NPI: 1396251468
Provider Name (Legal Business Name): LAKESHORE CARDIOVASCULAR INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8733 W 400 N
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

8733 W 400 N
MICHIGAN CITY IN
46360-9330
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-0333
  • Fax: 219-879-0325
Mailing address:
  • Phone: 219-878-3217
  • Fax: 224-633-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMMI M DALI
Title or Position: PRESIDENT
Credential: MD
Phone: 219-878-3217