Provider Demographics
NPI:1962654731
Name:LUNDEEN, JAMES EDGAR SR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDGAR
Last Name:LUNDEEN
Suffix:SR
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 1:26 SANDUSKY ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:44865-1113
Mailing Address - Country:US
Mailing Address - Phone:419-687-4322
Mailing Address - Fax:419-687-4323
Practice Address - Street 1:26 SANDUSKY ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:OH
Practice Address - Zip Code:44865-1113
Practice Address - Country:US
Practice Address - Phone:419-687-4322
Practice Address - Fax:419-687-4323
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350522572081P2900X, 208D00000X, 209800000X, 208VP0000X, 2084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0604322Medicaid
OH0808943OtherMEDICARE PTAN
OH0604322Medicaid