Basic Information
| Provider Information | |||||||||
| NPI: | 1861047060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUNSON MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319358000 | ||||||||
| FaxNumber: | 2319358099 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319358000 | ||||||||
| FaxNumber: | 2319358099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | BYERS | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2318767807 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNSON MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.