Basic Information
| Provider Information | |||||||||
| NPI: | 1477633139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUNDBERG | ||||||||
| FirstName: | GERSHOM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2421 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420017115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704506217 | ||||||||
| FaxNumber: | 2704506731 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420017115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704506217 | ||||||||
| FaxNumber: | 2704506731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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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 | 2085R0202X | 27871 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4338691 | 01 | KY | AETNA | OTHER | 150821 | 01 | KY | MEDICARE FDA # | OTHER | 1600014 | 01 | KY | UHC | OTHER | 193333 | 01 | KY | HEALTHLINK | OTHER | 5128682 | 01 | KY | CCN | OTHER | 000000068647 | 01 | KY | BCBS | OTHER | K004228 | 01 | KY | TRICARE | OTHER | 300019111 | 01 | KY | RR MEDICARE | OTHER | 64278716 | 05 | KY | MEDICAID |