MEDICARE: KATJE MARIE LEREW MUSGRAVE DO

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	207Q00000X	Family Medicine Physician	A-1644-11	NM
2	207Q00000X	Family Medicine Physician	5101018928	MI
3	207Q00000X	Family Medicine Physician	T0753	ME
4	207Q00000X	Family Medicine Physician	DR0053047	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	NMAAA2425	OTHER	CO	MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	NONE	OTHER	ME	RESIDENT-NO PROV #

General Provider Information

NPI Number	:	1144420787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATJE MARIE LEREW MUSGRAVE DO

Provider Business Mailing Address
First Line	:	500 WESTOVER DR # 16969
Second Line	:
City	:	SANFORD
State	:	NC
Zip	:	27330-8941
Country	:	US
Telephone Number	:	505-470-7498
Fax Number	:

Provider Business Practice Location Address
First Line	:	4650 SIGNAL TREE DR UNIT B200
Second Line	:
City	:	TIMNATH
State	:	CO
Zip	:	80547-4911
Country	:	US
Telephone Number	:	970-821-3830
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	11/04/2021

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