Provider Demographics
NPI:1801053426
Name:MUNSTER MEDICAL RESEARCH FOUNDATIO
Entity type:Organization
Organization Name:MUNSTER MEDICAL RESEARCH FOUNDATIO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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 1:505 WEST US HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2650
Mailing Address - Country:US
Mailing Address - Phone:219-322-3311
Mailing Address - Fax:219-322-8210
Practice Address - Street 1:505 WEST US HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-2650
Practice Address - Country:US
Practice Address - Phone:219-322-3311
Practice Address - Fax:219-322-8210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSTER MEDICAL RESEARCH FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-21
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200289040Medicaid
IN200902230AMedicaid
IN200902230AMedicaid
150240Medicare PIN