Provider Demographics
NPI:1578961660
Name:MUNSON HEALTHCARE GRAYLING
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE GRAYLING
Other - Org Name:MUNSON HEALTHCARE GRAYLING PHYSICIAN NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO EAST REGION
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:KORTH-WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-348-0720
Mailing Address - Street 1:3781 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5337
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1312
Practice Address - Country:US
Practice Address - Phone:231-935-6080
Practice Address - Fax:231-935-6081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSON HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 208D00000X
207X00000X, 208600000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty