MEDICARE: MR. MARKUS M MUNGER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	004051	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	65-0-G4-1223-0	OTHER	MI	BLUE CROSS AND BLUE SHIELD

General Provider Information

NPI Number	:	1225219561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARKUS M MUNGER

Provider Business Mailing Address
First Line	:	4351 24TH AVE
Second Line	:	SUITE 1
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4506
Country	:	US
Telephone Number	:	810-385-7405
Fax Number	:	810-385-7420

Provider Business Practice Location Address
First Line	:	4351 24TH AVE
Second Line	:	SUITE 1
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4506
Country	:	US
Telephone Number	:	810-385-7405
Fax Number	:	810-385-7420

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	08/04/2008

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Practice Fax: 810-385-7420

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