Provider Demographics
NPI:1558629592
Name:MUNSTER MEDICAL RESEARCH FOUNDATION, INC.
Entity Type:Organization
Organization Name:MUNSTER MEDICAL RESEARCH FOUNDATION, INC.
Other - Org Name:COMMUNITY CARE NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:P
Authorized Official - Last Name:FESKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-836-1600
Mailing Address - Street 1:9124A COLUMBIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2907
Mailing Address - Country:US
Mailing Address - Phone:219-440-7025
Mailing Address - Fax:219-440-7028
Practice Address - Street 1:9124A COLUMBIA AVENUE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2907
Practice Address - Country:US
Practice Address - Phone:219-440-7025
Practice Address - Fax:219-440-7028
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSTER MEDICAL RESEARCH FOUNDATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-27
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200289040Medicaid
IN150240Medicare PIN