Provider Demographics
NPI:1568645760
Name:MUNSTER MEDICAL RESEARCH FOUNDATION INC
Entity Type:Organization
Organization Name:MUNSTER MEDICAL RESEARCH FOUNDATION INC
Other - Org Name:COMMUNITY CARE NETWORK INTERNISTS
Other - Org Type:Other Name
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 1:9122 COLUMBIA AVE
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:219-836-3366
Mailing Address - Fax:219-836-3559
Practice Address - Street 1:9122 COLUMBIA AVE
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:219-836-3366
Practice Address - Fax:219-836-3559
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSTER MEDICAL RESEARCH FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200886130AMedicaid
IN90000970OtherBCBS OF ILLINOIS
IN200886130AMedicaid