Basic Information
| Provider Information | |||||||||
| NPI: | 1316098833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUNDINGER | ||||||||
| FirstName: | GERHARD | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 CHADWICK DR | ||||||||
| Address2: | SUITE 256 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392043463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013761934 | ||||||||
| FaxNumber: | 6013762005 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 CHADWICK DR | ||||||||
| Address2: | SUITE 256 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392043463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013761934 | ||||||||
| FaxNumber: | 6013762005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 11122 | MS | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 00116202 | 05 | MS | MEDICAID |