Basic Information
| Provider Information | |||||||||
| NPI: | 1699767897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANITTERSUM | ||||||||
| FirstName: | KORYN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317274444 | ||||||||
| FaxNumber: | 2317284789 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 PRAIRIE ST | ||||||||
| Address2: | SUITE 2600 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317277900 | ||||||||
| FaxNumber: | 2317277914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 06/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301076092 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | N28430074 | 01 | MI | MEDICARE | OTHER |