=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780827642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST INDIANA OCCUPATIONAL MEDICE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2009
-----------------------------------------------------
Last Update Date | 04/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 LAPORTE AVE
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-934-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 541 OTIS BOWEN DR
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-934-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JAMES VANVLIET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-934-5300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------