Basic Information
| Provider Information | |||||||||
| NPI: | 1003820200 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUND | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | MAKELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3650 E MILLS RD | ||||||||
| Address2: | |||||||||
| City: | PICKFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497749231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803806950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 LUDINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067863311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301079343 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1003820200 | 05 | MI | MEDICAID | LG079343 | 01 | MI | BLUE SHIELD | OTHER | 930117023 | 01 | MEDICARE - MULT - RAILROAD | OTHER | 4387722 | 05 | MI | MEDICAID | P00365745 | 01 | MEDICARE - MULT - RAILROAD | OTHER |