Provider Demographics
NPI:1477664993
Name:MUNSON DIALYSIS CENTER
Entity Type:Organization
Organization Name:MUNSON DIALYSIS CENTER
Other - Org Name:TRAVERSE BAY REGIONAL DIALYSIS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEPONIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-8237
Mailing Address - Street 1:4062 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8965
Mailing Address - Country:US
Mailing Address - Phone:231-935-5652
Mailing Address - Fax:231-935-7792
Practice Address - Street 1:4062 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8965
Practice Address - Country:US
Practice Address - Phone:231-935-0447
Practice Address - Fax:231-935-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08941OtherBCBS DIALYSIS
MI09479OtherBCBS SECONDARY DIALYSIS
MI2937976Medicaid
MI232528Medicare Oscar/Certification