Medical School Information |
|
Medical School Name
|
PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE
|
|
Individual professional's medical school
|
|
Graduation Year
|
2011
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
NEPHROLOGY
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
INTERNAL MEDICINE
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
INTERNAL MEDICINE
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
NORTHWEST INDIANA NEPHROLOGY PC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
3476715657
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
15
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
5615 US HWY 6
|
|
Group Practice or individual's line 1 address
|
|
City
|
PORTAGE
|
|
Group Practice or individual's city
|
|
State
|
IN
|
|
Group Practice or individual's state
|
|
Zip Code
|
463685213
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
2194626001
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
150035
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
PORTER REGIONAL HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
150034
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
ST MARY MEDICAL CENTER INC
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
150126
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
FRANCISCAN HEALTH CROWN POINT
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
150015
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
FRANCISCAN ST ANTHONY HEALTH - MICHIGAN CITY
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
150102
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
INDIANA UNIVERSITY HEALTH STARKE HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|