Provider Demographics
NPI:1558352401
Name:SUNDBERG, SYLVIA R (MD PHD)
Entity Type:Individual
Prefix:
First Name:SYLVIA
Middle Name:R
Last Name:SUNDBERG
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36933208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
110413OtherU CARE
763002OtherARAZ GROUP AMERICAS PPO
1202207OtherMEDICA HEALTH PLANS
36933OtherMN LICENSE NUMBER
HP28348OtherHEALTH PARTNERS
44132700OtherMEDICAL ASSISTANCE
1001397OtherPREFERRED ONE
51AA3SUOtherBLUE CROSS BLUE SHIELD
51AA3SUOtherBLUE CROSS BLUE SHIELD
370001384Medicare ID - Type Unspecified
51AA3SUOtherBLUE CROSS BLUE SHIELD