Basic Information
| Provider Information | |||||||||
| NPI: | 1952390106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDERSEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1216 RYANS RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561871722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073722921 | ||||||||
| FaxNumber: | 5073726523 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301069187 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35677 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080093188 | 01 | MI | METRAHEALTH | OTHER | 4540600 | 05 | MI | MEDICAID | 5659321 | 01 | MI | AETNA | OTHER | 010G56026 | 01 | MI | HEALTH PLUS | OTHER | 0802502771 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 080D410020 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 204375 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | F31478 | 01 | MI | HEALTH NET FEDERAL | OTHER | 204375 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | C4258 | 01 | MI | MCARE | OTHER | 080D410020 | 01 | MI | BLUE CARE NETWORK | OTHER | 7073962004 | 01 | MI | CIGNA | OTHER | F31478 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER |