MEDICARE: SCOTT B LUNDGREN D.O.

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	207L00000X	Anesthesiology Physician	007093	AZ
2	207L00000X	Anesthesiology Physician	36786-21	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	050081894	OTHER		RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225011315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT B LUNDGREN D.O.

Provider Business Mailing Address
First Line	:	13215 N 7TH ST STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-5300
Country	:	US
Telephone Number	:	602-805-5041
Fax Number	:	602-805-5013

Provider Business Practice Location Address
First Line	:	13215 N 7TH ST STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-5300
Country	:	US
Telephone Number	:	602-805-5041
Fax Number	:	602-805-5013

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	12/03/2024

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Directions to “ SCOTT B LUNDGREN D.O.” Practice Location

Language	Start Address	Practice Location

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