Basic Information
| Provider Information | |||||||||
| NPI: | 1558352401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDBERG | ||||||||
| FirstName: | SYLVIA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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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 | 208000000X | 36933 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110413 | 01 | U CARE | OTHER | 763002 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 1202207 | 01 | MEDICA HEALTH PLANS | OTHER | 36933 | 01 | MN LICENSE NUMBER | OTHER | BS2961149 | 01 | MN | DEA | OTHER | HP28348 | 01 | HEALTH PARTNERS | OTHER | 44132700 | 01 | MEDICAL ASSISTANCE | OTHER | 1001397 | 01 | PREFERRED ONE | OTHER | 51AA3SU | 01 | BLUE CROSS BLUE SHIELD | OTHER |