MEDICARE: NEPHROLOGY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1063412633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEPHROLOGY INC

Provider Business Mailing Address
First Line	:	221 RED COACH DRIVE
Second Line	:	SUITE D
City	:	MISHAWAKA
State	:	IN
Zip	:	46545-3519
Country	:	US
Telephone Number	:	574-273-6787
Fax Number	:	574-968-0882

Provider Business Practice Location Address
First Line	:	6201 NIMTZ PARKWAY
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-6117
Country	:	US
Telephone Number	:	574-246-7000
Fax Number	:	574-246-7007

Authorized Official
Title or Position	:	CEO
Name	:	KEITH MENTZ
Credential	:
Telephone Number	:	574-273-6787

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	08/22/2020

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