Basic Information
| Provider Information | |||||||||
| NPI: | 1881682813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUNDGRIN | ||||||||
| FirstName: | DARYL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 VIRGINIA WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 VIRGINIA WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
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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 | 207ZP0101X | MD25297 | TN | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | 43153 | KY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 100022075 | 01 | PHP OF TN | OTHER | 3031330 | 01 | TN | BCBS OF TN | OTHER | 264946 | 01 | BLACK LUNG | OTHER | TN0101 | 01 | JOHN DEER | OTHER | 3383335 | 05 | TN | MEDICAID | 89063XK | 05 | NC | MEDICAID | PAYSUB | 01 | TRIGON | OTHER | 220018743 | 01 | RAILROAD MEDICARE | OTHER | 00623235A | 05 | GA | MEDICAID | 1140001 | 01 | UNITED HEALTHCARE | OTHER |