MEDICARE: MUNSON MEDICAL CENTER

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	363LA2100X	Acute Care Nurse Practitioner	4704299582	MI
2	363A00000X	Physician Assistant	5601002557	MI
3	363A00000X	Physician Assistant	5601004425	MI
4	363A00000X	Physician Assistant	5601005943	MI
5	363A00000X	Physician Assistant	5601006097	MI
6	363LA2100X	Acute Care Nurse Practitioner	4704212770	MI
7	363LA2100X	Acute Care Nurse Practitioner	4704253480	MI
8	282N00000X	General Acute Care Hospital		MI

General Provider Information

NPI Number	:	1699174730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MUNSON MEDICAL CENTER

Provider Business Mailing Address
First Line	:	2513 MOMENTUM PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60689-5325
Country	:	US
Telephone Number	:	231-935-8031
Fax Number	:	231-935-6081

Provider Business Practice Location Address
First Line	:	2513 MOMENTUM PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60689-5325
Country	:	US
Telephone Number	:	231-935-8031
Fax Number	:	231-935-6081

Authorized Official
Title or Position	:	VP ANCILLARY SERVICES
Name	:	KATHLEEN LARAIA
Credential	:
Telephone Number	:	231-392-8410

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	04/01/2024

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Directions to “MUNSON MEDICAL CENTER ” Practice Location

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