Basic Information
| Provider Information | |||||||||
| NPI: | 1801815956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUNDEEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GILBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1108 | ||||||||
| Address2: | ATTN BARB SIMMONS | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481061108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346777400 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 ELM ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
| FaxNumber: | 9895842161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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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 | 4301023938 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CA3518 | 01 | MI | MEDICARE RR GROUP PIN | OTHER | 4085919 | 05 | MI | MEDICAID |