Provider Demographics
NPI:1225232572
Name:PAUL L GUNDERSON, M.D., P.C.
Entity Type:Organization
Organization Name:PAUL L GUNDERSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUSIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-772-4000
Mailing Address - Street 1:190 GROTON RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:AYER
Mailing Address - State:MA
Mailing Address - Zip Code:01432-1124
Mailing Address - Country:US
Mailing Address - Phone:978-772-4000
Mailing Address - Fax:978-772-6033
Practice Address - Street 1:190 GROTON RD
Practice Address - Street 2:SUITE 240
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1124
Practice Address - Country:US
Practice Address - Phone:978-772-4000
Practice Address - Fax:978-772-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210292332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0171671Medicaid
MAA32747Medicare PIN
MA0171671Medicaid
H44002Medicare UPIN