Provider Demographics
NPI:1720063746
Name:MUNSTER MEDICAL RESEARCH FOUNDATIO
Entity Type:Organization
Organization Name:MUNSTER MEDICAL RESEARCH FOUNDATIO
Other - Org Name:COMMUNITY SPINE AND NEUOSURGERY INSTITUTE
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 1:801 MACARTHUR BLVD
Mailing Address - Street 2:STE 405
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2919
Mailing Address - Country:US
Mailing Address - Phone:219-836-5167
Mailing Address - Fax:219-836-5249
Practice Address - Street 1:801 MACARTHUR BLVD
Practice Address - Street 2:STE 405
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2919
Practice Address - Country:US
Practice Address - Phone:219-836-5167
Practice Address - Fax:219-836-5249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSTER MEDICAL RESEARCH FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-13
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDE3851OtherMEDICARE RR
IN200261490DMedicaid
IN000000383680OtherANTHEM BCBS
INDE3851OtherMEDICARE RAILROAD
INDE3851OtherMEDICARE RR
IN000000383680OtherANTHEM BCBS