Healthcare Provider Details

I. General information

NPI: 1780684449
Provider Name (Legal Business Name): ILLIANA SURGERY AND MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 US HIGHWAY 6 STE 3
PORTAGE IN
46368-5111
US

IV. Provider business mailing address

701 SUPERIOR AVE ATTN: MANAGED CARE
MUNSTER IN
46321-4037
US

V. Phone/Fax

Practice location:
  • Phone: 219-641-3051
  • Fax:
Mailing address:
  • Phone: 219-641-3051
  • Fax: 219-641-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: VIJAY GUPTA
Title or Position: CEO
Credential: M.D.
Phone: 219-922-4200