1952390106 NPI number — DR. MARK R GUNDERSEN MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952390106 NPI number — DR. MARK R GUNDERSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNDERSEN
Provider First Name:
MARK
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1952390106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1216 RYANS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORTHINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56187-1722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-372-2921
Provider Business Mailing Address Fax Number:
507-372-6523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 SOUTH CASCADE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERGUS FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56537-2813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-736-8000
Provider Business Practice Location Address Fax Number:
218-739-6742
Provider Enumeration Date:
10/20/2005

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: 207Q00000X , with the licence number:  4301069187 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35677 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080093188 . This is a "METRAHEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4540600 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5659321 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 010G56026 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0802502771 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 204375 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F31478 . This is a "HEALTH NET FEDERAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 204375 . This is a "HEALTH ADVANTAGE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C4258 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7073962004 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F31478 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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