Provider Demographics
NPI:1972503548
Name:NEPHROLOGY INC
Entity Type:Organization
Organization Name:NEPHROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-273-6787
Mailing Address - Street 1:221 RED COACH DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3519
Mailing Address - Country:US
Mailing Address - Phone:574-273-6787
Mailing Address - Fax:574-968-0882
Practice Address - Street 1:700 WATERBURY PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2339
Practice Address - Country:US
Practice Address - Phone:574-294-4444
Practice Address - Fax:574-295-7400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
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
IN152530Medicare ID - Type Unspecified