Basic Information
Provider Information | |||||||||
NPI: | 1891780771 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUNSON | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 6TH AVE | ||||||||
Address2: | STE 340 | ||||||||
City: | LEAVENWORTH | ||||||||
State: | KS | ||||||||
PostalCode: | 660483222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136517151 | ||||||||
FaxNumber: | 9137728283 | ||||||||
Practice Location | |||||||||
Address1: | 1001 6TH AVE | ||||||||
Address2: | STE 340 | ||||||||
City: | LEAVENWORTH | ||||||||
State: | KS | ||||||||
PostalCode: | 660483222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136517151 | ||||||||
FaxNumber: | 9137728283 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2005 | ||||||||
LastUpdateDate: | 02/06/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME99011 | FL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 04-36268 | KS | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 100089230A | 05 | OK |   | MEDICAID | 310057 | 01 | FL | AVMED | OTHER | 326359 | 01 | FL | AMERIGROUP | OTHER | 4609279 | 01 | FL | AETNA | OTHER | 15633601 | 01 | FL | CITRUS HEALTHCARE | OTHER | NPI | 01 | FL | PHYSICAINS UNITED PLAN | OTHER | 410407 | 01 | FL | WELLCARE | OTHER | 09 04730 | 01 | FL | UHC | OTHER | ME99011 | 01 | FL | LICENSE | OTHER | 01361 | 01 | FL | BCBS OF FLORIDA | OTHER | 1497748743 | 01 | FL | GROUP NPI NUMBER /LRHSI | OTHER | 15042 | 01 | FL | UNIVERSAL HEALTHCARE | OTHER | 278877200 | 05 | FL |   | MEDICAID | 2568340 | 01 | FL | CIGNA | OTHER | DA5786 | 01 | FL | RAILROAD MEDICARE GROUP NUMBER | OTHER |