=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083761860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUNSON MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 SIXTH ST STE 208
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-2360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-935-2045
-----------------------------------------------------
Fax | 231-935-2046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2513 MOMENTUM PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60689-5325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-935-6080
-----------------------------------------------------
Fax | 231-935-6081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO MUNSON PHYSICIAN NETWORK
-----------------------------------------------------
Name | BONNIE KRUSZKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-935-4995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------