MEDICARE: PHILIP LUNDQUIST RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2117	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6401358	OTHER	MN	MEDICA
2	8B509LU	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1528159894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP LUNDQUIST RPT

Provider Business Mailing Address
First Line	:	101 SHOREWOOD DR APT 23
Second Line	:
City	:	INTERNATIONAL FALLS
State	:	MN
Zip	:	56649-2126
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 HIGHWAY 71
Second Line	:
City	:	INTERNATIONAL FALLS
State	:	MN
Zip	:	56649-2154
Country	:	US
Telephone Number	:	763-689-5385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/09/2007

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