Healthcare Provider Details

I. General information

NPI: 1679040224
Provider Name (Legal Business Name): STREAM CLINICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 45TH ST
MUNSTER IN
46321-3917
US

IV. Provider business mailing address

204 LEGACY PLZ W
LA PORTE IN
46350-5285
US

V. Phone/Fax

Practice location:
  • Phone: 219-476-7246
  • Fax: 219-242-8972
Mailing address:
  • Phone: 219-476-7246
  • Fax: 219-242-8972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHETAN PURANIK
Title or Position: MEMBER
Credential: MD
Phone: 219-476-7246