Provider Demographics
NPI:1376513770
Name:SUNDBY, SCOTT A (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:SUNDBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-6841
Mailing Address - Fax:320-762-6847
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-6841
Practice Address - Fax:320-762-6847
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46118174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0118131OtherMEDICA
MN132077D277OtherUCARE
MN2152665OtherAMERICA'S PPO
MNA023OtherCHAMPUS
MNHP42878OtherHEALTH PARTNERS
MN580602000Medicaid
MN1040951OtherPREFERRED ONE
MN462T5SUOtherBLUE SHIELD
MN080013175Medicare ID - Type Unspecified
MN1040951OtherPREFERRED ONE