Provider Demographics
NPI:1922030162
Name:MUNSON MEDICAL CENTER
Entity Type:Organization
Organization Name:MUNSON MEDICAL CENTER
Other - Org Name:MUNSON FAMILY PRACTICE RESIDENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HEPLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-5000
Mailing Address - Street 1:2513 MOMENTUM PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:1400 MEDICAL CAMPUS DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7823
Practice Address - Country:US
Practice Address - Phone:231-935-8000
Practice Address - Fax:231-935-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21014OtherPRIORITY HEALTH GROUP #
MICB9942OtherRAILROAD MEDICARE GROUP #
MI080B812900OtherBCBS GROUP NUMBER
MI700B860160OtherBCBS GROUP NUMBER
0B86016Medicare PIN