Healthcare Provider Details

I. General information

NPI: 1396845491
Provider Name (Legal Business Name): NORTHERN INDIANA OCCUPATIONAL MEDICINE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 LANCER ST
PORTAGE IN
46368-4495
US

IV. Provider business mailing address

PO BOX 2028
PORTAGE IN
46368-5528
US

V. Phone/Fax

Practice location:
  • Phone: 219-364-3161
  • Fax: 219-764-8463
Mailing address:
  • Phone: 440-716-1283
  • Fax: 440-716-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELA LEICHT
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 219-763-6423