Provider Demographics
NPI:1336229947
Name:LUNDBERG MEDICAL IMAGING PSC
Entity Type:Organization
Organization Name:LUNDBERG MEDICAL IMAGING PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERSHOM
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-442-8272
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:270-442-8272
Mailing Address - Fax:270-444-0539
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:270-442-8272
Practice Address - Fax:270-444-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4932OtherBCBS
KY7100152590Medicaid
KY150821OtherFDA #
2398OtherMEDICARE PTIN
150821OtherFDA NUMBER