Provider Demographics
NPI:1902994924
Name:PORTER COUNTY ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:PORTER COUNTY ENDOSCOPY CENTER, LLC
Other - Org Name:ENDOLABS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-934-5300
Mailing Address - Street 1:2206 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2749
Mailing Address - Country:US
Mailing Address - Phone:219-548-9990
Mailing Address - Fax:
Practice Address - Street 1:2206 ROOSEVELT RD
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2749
Practice Address - Country:US
Practice Address - Phone:219-548-9990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004288261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200513280AMedicaid
IN200513280AMedicaid