Healthcare Provider Details

I. General information

NPI: 1447859558
Provider Name (Legal Business Name): MUNSON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3074 N US 31 S
TRAVERSE CITY MI
49684-4533
US

IV. Provider business mailing address

3074 N US 31 S
TRAVERSE CITY MI
49684-4533
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0535
  • Fax: 231-935-0984
Mailing address:
  • Phone: 231-935-0535
  • Fax: 231-935-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARK HEPLER
Title or Position: CFO
Credential:
Phone: 231-935-6512