Provider Demographics
NPI:1336230788
Name:SHIAWASSEE PEDIATRICS PC
Entity Type:Organization
Organization Name:SHIAWASSEE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-729-4848
Mailing Address - Street 1:802 W KING ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2100
Mailing Address - Country:US
Mailing Address - Phone:989-729-4848
Mailing Address - Fax:989-729-4849
Practice Address - Street 1:802 W KING ST
Practice Address - Street 2:SUITE C
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2100
Practice Address - Country:US
Practice Address - Phone:989-729-4848
Practice Address - Fax:989-729-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704113660163WG0000X
MI4301029347208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1012477OtherMCLAREN HEALTH PLANS
MI3507810231OtherBCBS
MI1200321OtherPHYSICIAN HEALTH PLAN
MI4924725Medicaid
MI4671219Medicaid
MI0982812OtherHEALTHPLUS
MI4671219Medicaid