Organization
NORTHSHORE HEALTH CENTERS, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID HALL (CEO)
(219) 763-8112
Entity
Organization
Contact information
Practice address
3099 CENTRAL AVE, LAKE STATION, IN 46405-2207
(219) 763-8112
(219) 962-1189
Mailing address
PO BOX 1430, PORTAGE, IN 46368-9230
(219) 763-8112
(219) 764-5380
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
—
—
124Q00000X
Dental Hygienist
—
—
2085B0100X
Body Imaging Physician
—
—
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
151869
MEDICARE PART A PTAN
IN
01
—
191360
MEDICARE PART B PTAN
IN
05
—
200331170C
—
IN
Enumeration date
10/23/2007
Last updated
09/22/2020
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