=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093758567
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIK W. GUNDERSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 02/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 824 ILLINOIS AVE
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-342-7750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 ONEIDA VALLEY RD STE 211
-----------------------------------------------------
City | BUTLER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16001-2252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-342-7750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 21024
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 70421
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MD462923
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------