Basic Information
| Provider Information | |||||||||
| NPI: | 1336229947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUNDBERG MEDICAL IMAGING PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2421 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420017115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704428272 | ||||||||
| FaxNumber: | 2704440539 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420017115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704428272 | ||||||||
| FaxNumber: | 2704440539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | LUNDBERG | ||||||||
| AuthorizedOfficialFirstName: | GERSHOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2704428272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4932 | 01 | KY | BCBS | OTHER | 7100152590 | 05 | KY | MEDICAID | 150821 | 01 | KY | FDA # | OTHER | 2398 | 01 | MEDICARE PTIN | OTHER | 150821 | 01 | FDA NUMBER | OTHER |