Provider Demographics
NPI:1417033143
Name:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Entity type:Organization
Organization Name:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO MUNSON PHYSICIAN NETWORK
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSZKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-4995
Mailing Address - Street 1:14700 LAKE SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1931
Mailing Address - Country:US
Mailing Address - Phone:231-547-4024
Mailing Address - Fax:231-547-8088
Practice Address - Street 1:14700 LAKE SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1931
Practice Address - Country:US
Practice Address - Phone:231-547-4024
Practice Address - Fax:231-547-8088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-27
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1001019OtherNORTHERN HEALTH PLAN
MI20139OtherPRIORITY HEALTH PROFESSIO
MI700A560010OtherBCBS MULTI GROUP
MICAOtherJVHL
MI700A560010OtherBCN PROFESSINAL MULTI GRP
CD9821OtherMEDICARE RAILROAD GROUP
MI134141100OtherCOMP CARRIER US POSTAL SV
MICAOtherJVHL
0A56001Medicare PIN
MI=========OtherPPO NEXT