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General NPI Number Information
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NPI Number | 1043307978
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Entity Type | Organization
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Legal Business Name | NEIL WANGSTROM MD PC
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 09/29/2009
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Provider Practice Location Address
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Address Line | 304 DETROIT ST
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City | LA PORTE
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State | IN
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Zip | 46350-2473
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Country | US
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Telephone | 219-325-3770
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Fax | 219-325-8181
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Provider Business Mailing Address
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Address Line | 304 DETROIT ST
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City | LA PORTE
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State | IN
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Zip | 46350-2473
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Country | US
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Telephone | 219-325-3770
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Fax | 219-325-8181
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. ROBIN M HENRICH
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Credential | CMPC
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Telephone | 219-325-3770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 23002292A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71001701A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71001740A
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 01038858
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License Number State | IN
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