MEDICARE: DR. MICHAEL OWEN MUSTY SR. MD

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	207R00000X	Internal Medicine Physician	20818	MN

General Provider Information

NPI Number	:	1700947082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL OWEN MUSTY SR. MD

Provider Business Mailing Address
First Line	:	10710 PINE BEACH PENINSULA LOOP
Second Line	:
City	:	EAST GULL LAKE
State	:	MN
Zip	:	56401-2027
Country	:	US
Telephone Number	:	218-330-1139
Fax Number	:

Provider Business Practice Location Address
First Line	:	10710 PINE BEACH PENINSULA LOOP
Second Line	:
City	:	EAST GULL LAKE
State	:	MN
Zip	:	56401-2027
Country	:	US
Telephone Number	:	218-330-1139
Fax Number	:

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	09/16/2011

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