Healthcare Provider Details

I. General information

NPI: 1407710759
Provider Name (Legal Business Name): IAN W MUNGER IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43401 N JEFFERSON AVE
SELFRIDGE MI
48045-5266
US

IV. Provider business mailing address

1837 W STATE BLVD
FORT WAYNE IN
46808-1933
US

V. Phone/Fax

Practice location:
  • Phone: 586-239-4971
  • Fax:
Mailing address:
  • Phone: 419-670-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: