Provider Demographics
NPI:1699767897
Name:VANITTERSUM, KORYN M (MD)
Entity type:Individual
Prefix:DR
First Name:KORYN
Middle Name:M
Last Name:VANITTERSUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:6401 PRAIRIE ST
Practice Address - Street 2:SUITE 2600
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-727-7900
Practice Address - Fax:231-727-7914
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301076092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN28430074OtherMEDICARE
MIN28430074OtherMEDICARE