Provider Demographics
NPI:1366444127
Name:END STAGE RENAL DISEASE CARE PC
Entity Type:Organization
Organization Name:END STAGE RENAL DISEASE CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:HASLITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD MPH
Authorized Official - Phone:765-287-0248
Mailing Address - Street 1:2701 W NORTH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3415
Mailing Address - Country:US
Mailing Address - Phone:765-287-0248
Mailing Address - Fax:765-287-0265
Practice Address - Street 1:2701 W NORTH ST
Practice Address - Street 2:SUITE C
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3415
Practice Address - Country:US
Practice Address - Phone:765-287-0248
Practice Address - Fax:765-287-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50002637A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN206210Medicare PIN