Basic Information
| Provider Information | |||||||||
| NPI: | 1194752345 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUNSON MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1131 | ||||||||
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| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496851131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319355000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1105 6TH ST | ||||||||
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| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496842349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319355000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AMBULATORY CLINICS | ||||||||
| AuthorizedOfficialTelephone: | 2319355000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.