1881682813 NPI number — DARYL B LUNDGRIN MD

Table of content: DARYL B LUNDGRIN MD (NPI 1881682813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881682813 NPI number — DARYL B LUNDGRIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDGRIN
Provider First Name:
DARYL
Provider Middle Name:
B
Provider Name Prefix Text:
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:
1881682813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 VIRGINIA WAY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-221-4474
Provider Business Mailing Address Fax Number:
615-234-3774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 VIRGINIA WAY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
BRENTWOOD
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37027-7541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-221-4474
Provider Business Practice Location Address Fax Number:
615-234-3774
Provider Enumeration Date:
10/13/2005

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: 207ZP0101X , with the licence number:  MD25297 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 43153 , 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: 100022075 . This is a "PHP OF TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3031330 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 264946 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "JOHN DEER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3383335 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89063XK , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAYSUB . This is a "TRIGON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 220018743 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00623235A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1140001 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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