Provider Demographics
NPI:1194425447
Name:MUNSON MEDICAL CENTER
Entity type:Organization
Organization Name:MUNSON MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, ANCILLARY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-392-8410
Mailing Address - Street 1:FOSTER FAMILY COMMUNITY HEALTH CENTER
Mailing Address - Street 2:550 MUNSON AVE UNIT 4
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-935-8736
Mailing Address - Fax:231-213-8716
Practice Address - Street 1:FOSTER FAMILY COMMUNITY HEALTH CENTER
Practice Address - Street 2:550 MUNSON AVE UNIT 4
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-935-8736
Practice Address - Fax:231-213-8716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSON MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-06
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171477Medicaid