1952678757 NPI number — MUNSON DIALYSIS CENTER

Table of content: (NPI 1952678757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952678757 NPI number — MUNSON DIALYSIS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUNSON DIALYSIS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ELIZABETH C. HOSICK DIALYSIS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952678757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4062 W ROYAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-8965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-935-5652
Provider Business Mailing Address Fax Number:
231-935-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49635-9658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-352-2922
Provider Business Practice Location Address Fax Number:
231-352-2924
Provider Enumeration Date:
11/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DEPONIO
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, SUPPLY CHAIN; PRESIDENT, NMSA
Authorized Official Telephone Number:
231-935-0447

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: K8919 . This is a "BCBS DIALYSIS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: K9420 . This is a "BCBS SECONDARY DIALYSIS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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