Active NPI
Koryn M Vanittersum, M.D.
- Family Medicine Physician
- Muskegon, MI
National Provider Identifier
1699767897
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 4301076092
- Practice address
- 6401 Prairie St
Suite 2600
Muskegon, MI 49444 - Phone
- (231) 727-7900
- Fax
- (231) 727-7914
- NPI assigned
- Aug 16, 2005
- Last updated
- Jun 20, 2013
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 4301076092 | MI | Primary |
Addresses
Primary practice location
6401 Prairie St
Suite 2600
Muskegon, MI 49444
Mailing address
PO Box 1848
Muskegon, MI 49443-1848
Phone (231) 727-4444
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| N28430074 | Other | MI | MEDICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4301076092 | MI | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lakeshore Derm & Laser Center PLC | Current | Accepting new patients | |
| HPCN | Family Medicine | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
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- Norton Shores, MI
- NPI 1538209945
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1124150400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1371686400000",
"number": "1699767897",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1848",
"city": "MUSKEGON",
"state": "MI",
"postal_code": "494431848",
"telephone_number": "231-727-4444",
"fax_number": "231-728-4789"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6401 PRAIRIE ST",
"address_2": "SUITE 2600",
"city": "MUSKEGON",
"state": "MI",
"postal_code": "49444",
"telephone_number": "231-727-7900",
"fax_number": "231-727-7914"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VANITTERSUM",
"first_name": "KORYN",
"middle_name": "M",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-08-16",
"last_updated": "2013-06-20",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MI",
"license": "4301076092",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE",
"identifier": "N28430074",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Muskegon, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.