1477633139 NPI number — MR. GERSHOM LUNDBERG M.D

Table of content: MR. GERSHOM LUNDBERG M.D (NPI 1477633139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477633139 NPI number — MR. GERSHOM LUNDBERG M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDBERG
Provider First Name:
GERSHOM
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477633139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2421 BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42001-7115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-450-6217
Provider Business Mailing Address Fax Number:
270-450-6731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2421 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-7115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-450-6217
Provider Business Practice Location Address Fax Number:
270-450-6731
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  27871 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4338691 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 150821 . This is a "MEDICARE FDA #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1600014 . This is a "UHC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 193333 . This is a "HEALTHLINK" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5128682 . This is a "CCN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000068647 . This is a "BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: K004228 . This is a "TRICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 300019111 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64278716 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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