Healthcare Provider Details

I. General information

NPI: 1699174730
Provider Name (Legal Business Name): MUNSON MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2513 MOMENTUM PL
CHICAGO IL
60689-5325
US

IV. Provider business mailing address

2513 MOMENTUM PL
CHICAGO IL
60689-5325
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-8031
  • Fax: 231-935-6081
Mailing address:
  • Phone: 231-935-8031
  • Fax: 231-935-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002557
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004425
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005943
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006097
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704212770
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704253480
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704299582
License Number StateMI

VIII. Authorized Official

Name: KATHLEEN LARAIA
Title or Position: VP ANCILLARY SERVICES
Credential:
Phone: 231-392-8410