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General NPI Number Information
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NPI Number | 1699767897
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Entity Type | Individual
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Provider Name | KORYN M VANITTERSUM M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/16/2005
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Last Update Date | 06/20/2013
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Provider Practice Location Address
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Address Line | 6401 PRAIRIE ST SUITE 2600
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City | MUSKEGON
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State | MI
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Zip | 49444
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Country | US
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Telephone | 231-727-7900
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Fax | 231-727-7914
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Provider Business Mailing Address
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Address Line | PO BOX 1848
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City | MUSKEGON
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State | MI
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Zip | 49443-1848
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Country | US
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Telephone | 231-727-4444
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Fax | 231-728-4789
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301076092
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License Number State | MI
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