Healthcare Provider Details

I. General information

NPI: 1316138522
Provider Name (Legal Business Name): MARK L. LUNDINE M.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 10/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6979 REDANSA DR
ROCKFORD IL
61108-1201
US

IV. Provider business mailing address

6979 REDANSA DR
ROCKFORD IL
61108-1201
US

V. Phone/Fax

Practice location:
  • Phone: 815-226-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number336023733
License Number StateIL

VIII. Authorized Official

Name: MARK L LUNDINE
Title or Position: PRESIDENT
Credential:
Phone: 815-226-1800