Basic Information
| Provider Information | |||||||||
| NPI: | 1336230788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHIAWASSEE PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 W KING ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488672100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897294848 | ||||||||
| FaxNumber: | 9897294849 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 W KING ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488672100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897294848 | ||||||||
| FaxNumber: | 9897294849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MUNSON | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9897294848 | ||||||||
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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 | 208000000X | 4301029347 | MI | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 163WG0000X | 4704113660 | MI | X | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1012477 | 01 | MI | MCLAREN HEALTH PLANS | OTHER | 3507810231 | 01 | MI | BCBS | OTHER | 1200321 | 01 | MI | PHYSICIAN HEALTH PLAN | OTHER | 4924725 | 05 | MI | MEDICAID | 4671219 | 05 | MI | MEDICAID | 0982812 | 01 | MI | HEALTHPLUS | OTHER |