Basic Information
| Provider Information | |||||||||
| NPI: | 1932277472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDERSON | ||||||||
| FirstName: | HEIDI | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139168144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162600 | ||||||||
| FaxNumber: | 3139163235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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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 | 207R00000X | 5101015863 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 5101015863 | MI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.