Healthcare Provider Details

I. General information

NPI: 1598131617
Provider Name (Legal Business Name): MUNSON HEALTHCARE GRAYLING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 LAKE ST
ROSCOMMON MI
48653-9203
US

IV. Provider business mailing address

3778 MOMENTUM PL
CHICAGO IL
60689-5337
US

V. Phone/Fax

Practice location:
  • Phone: 989-275-1200
  • Fax:
Mailing address:
  • Phone: 989-275-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BONNIE KRUSZKA
Title or Position: COO MUNSON PHYSICIAN NETWORK
Credential:
Phone: 231-935-4995