Provider Demographics
NPI:1386638906
Name:LUNDEBERG, JOHN D (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:LUNDEBERG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1239 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3175
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-529-0586
Practice Address - Street 1:2 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-684-3156
Practice Address - Fax:618-529-0529
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041181507367500000X
IL209001325367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherGROUP PTAN