Provider Demographics
NPI:1477633139
Name:LUNDBERG, GERSHOM (MD)
Entity Type:Individual
Prefix:MR
First Name:GERSHOM
Middle Name:
Last Name:LUNDBERG
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 1:2421 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7115
Mailing Address - Country:US
Mailing Address - Phone:270-450-6217
Mailing Address - Fax:270-450-6731
Practice Address - Street 1:2421 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7115
Practice Address - Country:US
Practice Address - Phone:270-450-6217
Practice Address - Fax:270-450-6731
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4338691OtherAETNA
KY150821OtherMEDICARE FDA #
KY1600014OtherUHC
KY193333OtherHEALTHLINK
KY5128682OtherCCN
KY000000068647OtherBCBS
KYK004228OtherTRICARE
KY300019111OtherRR MEDICARE
KY64278716Medicaid
KY150821OtherMEDICARE FDA #
KY1600014OtherUHC