Healthcare Provider Details

I. General information

NPI: 1912296682
Provider Name (Legal Business Name): PORTER NEONATAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 LAPORTE AVE
VALPARAISO IN
46383-5860
US

IV. Provider business mailing address

2304 KOSSUTH ST
LAFAYETTE IN
47904-3240
US

V. Phone/Fax

Practice location:
  • Phone: 219-263-4600
  • Fax:
Mailing address:
  • Phone: 765-446-9600
  • Fax: 765-446-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROSARIO CHUA
Title or Position: PRESIDENT
Credential: MD
Phone: 765-446-9600