1053621425 NPI number — MUNSTER MEDICAL RESEARCH FOUNDATION INC

Table of content: (NPI 1053621425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053621425 NPI number — MUNSTER MEDICAL RESEARCH FOUNDATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUNSTER MEDICAL RESEARCH FOUNDATION INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMMUNITY HOSPITAL WOUND OSTOMY CLINIC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053621425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MACARTHUR BLVD
Provider Second Line Business Mailing Address:
1ST FLOOR WEST PAVILION
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-2901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-836-7713
Provider Business Mailing Address Fax Number:
219-836-7083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
1ST FLOOR WEST PAVILION
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-2901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-836-7713
Provider Business Practice Location Address Fax Number:
219-836-7083
Provider Enumeration Date:
10/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FESKO
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
219-836-1600

Provider Taxonomy Codes

  • Taxonomy code: 364S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364SA2100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SM0705X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100270570 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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