Basic Information
| Provider Information | |||||||||
| NPI: | 1023297017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUNTZ | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAURITZEN | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 925 E SUPERIOR ST | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558022238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187223700 | ||||||||
| FaxNumber: | 2187228705 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 E SUPERIOR ST | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558022238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187223700 | ||||||||
| FaxNumber: | 2187228705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 52482-20 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 56970 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.