Basic Information
| Provider Information | |||||||||
| NPI: | 1225101660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUSKEGON SURGICAL ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317399461 | ||||||||
| FaxNumber: | 2317338131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1316 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317399461 | ||||||||
| FaxNumber: | 2317338131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | ZONCA | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PLASTIC SURGERY | ||||||||
| AuthorizedOfficialTelephone: | 2317399461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 225XH1200X | 5201006378 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CE6022 | 01 | MEDICARE RR | OTHER |