Provider Demographics
NPI:1699174730
Name:MUNSON MEDICAL CENTER
Entity type:Organization
Organization Name:MUNSON MEDICAL CENTER
Other - Org Name:
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 1:2513 MOMENTUM PL
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:231-935-8031
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:2513 MOMENTUM PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60689-5325
Practice Address - Country:US
Practice Address - Phone:231-935-8031
Practice Address - Fax:231-935-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI282N00000X
MI5601002557363A00000X
MI5601004425363A00000X
MI5601005943363A00000X
MI5601006097363A00000X
MI4704212770363LA2100X
MI4704253480363LA2100X
MI4704299582363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty