Basic Information
| Provider Information | |||||||||
| NPI: | 1013133487 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL HEALTH SYSTEM, INC. | ||||||||
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| OtherOrganizationName: | LAPORTE PT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 328 N MICHIGAN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471069 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 I ST | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463505533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193241700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COSTELLO | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP-CFO | ||||||||
| AuthorizedOfficialTelephone: | 5746473549 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000178974 | 01 | IN | ANTHEM | OTHER |