Healthcare Provider Details

I. General information

NPI: 1649381021
Provider Name (Legal Business Name): LAPORTE REGIONAL PHYSICIAN NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 MICHIGAN ST
WALKERTON IN
46574-1116
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 574-586-3114
  • Fax: 574-586-7815
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RHONDA VOLK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 219-326-2485