Provider Demographics
NPI:1144626052
Name:MUNSON HEALTHCARE GRAYLING
Entity type:Organization
Organization Name:MUNSON HEALTHCARE GRAYLING
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 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2349
Mailing Address - Country:US
Mailing Address - Phone:231-935-5000
Mailing Address - Fax:
Practice Address - Street 1:2585 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9624
Practice Address - Country:US
Practice Address - Phone:989-366-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSON HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-05
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00030OtherBLUE CROSS
MI238562Medicaid
MI238562Medicaid