MEDICARE: DR. KORYN M VANITTERSUM M.D.

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	207Q00000X	Family Medicine Physician	4301076092	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	N28430074	OTHER	MI	MEDICARE

General Provider Information

NPI Number	:	1699767897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KORYN M VANITTERSUM M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1848
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49443-1848
Country	:	US
Telephone Number	:	231-727-4444
Fax Number	:	231-728-4789

Provider Business Practice Location Address
First Line	:	6401 PRAIRIE ST
Second Line	:	SUITE 2600
City	:	MUSKEGON
State	:	MI
Zip	:	49444
Country	:	US
Telephone Number	:	231-727-7900
Fax Number	:	231-727-7914

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	06/20/2013

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