Provider Demographics
NPI:1922008689
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: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 1:9660 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-365-1166
Mailing Address - Fax:219-365-8852
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-365-1166
Practice Address - Fax:219-365-8852
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSTER MEDICAL RESEARCH FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X, 207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200289040Medicaid
IL90000970OtherBCBS OF ILLINOIS
INCH9533OtherMEDICARE RAILROAD
IN150240Medicare PIN