=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396845491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN INDIANA OCCUPATIONAL MEDICINE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3220 LANCER ST
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-4495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-364-3161
-----------------------------------------------------
Fax | 219-764-8463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2028
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-716-1283
-----------------------------------------------------
Fax | 440-716-1605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNT MANAGER
-----------------------------------------------------
Name | MS. ANGELA LEICHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-763-6423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------