Provider Demographics
NPI:1477765014
Name:GUNDERSON, TYLER G (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:G
Last Name:GUNDERSON
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 1:118 BROWN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-7740
Mailing Address - Country:US
Mailing Address - Phone:931-484-8861
Mailing Address - Fax:865-374-2116
Practice Address - Street 1:118 BROWN AVE STE 103
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555
Practice Address - Country:US
Practice Address - Phone:931-484-8861
Practice Address - Fax:865-374-2116
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-117892207X00000X
TN58038207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-117892OtherPHYSICIAN LICENSE
ILK39375OtherMEDICARE
TNQ041304Medicaid
IL036117892Medicaid