Basic Information
| Provider Information | |||||||||
| NPI: | 1033186903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IDUN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVENUE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7172174217 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172677164 | ||||||||
| FaxNumber: | 7172677414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA08022800 | NJ | N | Other Service Providers | Specialist | 207LP2900X | MD425631 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | MD425631 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 10156623 0002 | 05 | PA | MEDICAID | 25-1716306 | 01 | PA | INTERGROUP | OTHER | 25-1716306 | 01 | PA | HEALTHNET/TRICARE | OTHER | 25-1716306 | 01 | PA | FIRST HEALTH | OTHER | BI9399278 | 01 | PA | DEA | OTHER | G920-0101/85XWCU | 01 | PA | CAREFIRST | OTHER | 1928717 | 01 | PA | AETNA HMO | OTHER | 25-1716306 | 01 | PA | SOUTH CENTRAL PREFERRED | OTHER | P00627622 | 01 | PA | RAILROAD MEDICARE | OTHER | 001828361 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 50079823 | 01 | PA | CAPITAL BLUECROSS | OTHER | 7788804 | 01 | PA | AETNA NON-HMO | OTHER | 25-1716306 | 01 | PA | MULTIPLAN/PHCS | OTHER | MD425631 | 01 | PA | MEDICAL LICENSE | OTHER | PEARL | 01 | PA | HEALTH AMERICA | OTHER | 2183091 | 01 | PA | MAMSI | OTHER | 25-1716306 | 01 | PA | DEVON | OTHER | 050514 | 01 | PA | MEDICARE GROUP # | OTHER | 120420418 | 01 | PA | DEPT OF LABOR | OTHER | 1573434 | 01 | PA | GATEWAY | OTHER | 240951 | 01 | PA | UNISON | OTHER | 25-1716306 | 01 | PA | INFORMED | OTHER |