Provider Demographics
NPI:1730294570
Name:EVEREST HEALTHCARE INDIANA, INC.
Entity Type:Organization
Organization Name:EVEREST HEALTHCARE INDIANA, INC.
Other - Org Name:TRI-COUNTIES DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-402-9000
Mailing Address - Street 1:817 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-1891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 S 13TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1891
Practice Address - Country:US
Practice Address - Phone:260-724-8303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
152538Medicare ID - Type Unspecified