Provider Demographics
NPI:1497854780
Name:WILLIAM BRUCE LUNDEEN MD PC
Entity Type:Organization
Organization Name:WILLIAM BRUCE LUNDEEN MD PC
Other - Org Name:RADIATION THERAPY ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:LUNDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-766-8052
Mailing Address - Street 1:12310 PINECREST RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1653
Mailing Address - Country:US
Mailing Address - Phone:703-860-1178
Mailing Address - Fax:703-860-1266
Practice Address - Street 1:1701 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3610
Practice Address - Country:US
Practice Address - Phone:703-558-6284
Practice Address - Fax:703-558-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101012571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7276192Medicaid
VAB94238Medicare UPIN
VA083906Medicare ID - Type Unspecified