Basic Information
| Provider Information | |||||||||
| NPI: | 1922030162 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNSON MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | MUNSON FAMILY PRACTICE RESIDENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2513 MOMENTUM PLACE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319356080 | ||||||||
| FaxNumber: | 2319356081 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319358000 | ||||||||
| FaxNumber: | 2319358099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | HEPLER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2319355000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 21014 | 01 | MI | PRIORITY HEALTH GROUP # | OTHER | CB9942 | 01 | MI | RAILROAD MEDICARE GROUP # | OTHER | 080B812900 | 01 | MI | BCBS GROUP NUMBER | OTHER | 700B860160 | 01 | MI | BCBS GROUP NUMBER | OTHER |