Provider Demographics
NPI:1063433456
Name:SUNDBERG, THOMAS C (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:SUNDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-9300
Mailing Address - Fax:704-302-9301
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 4100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4378
Practice Address - Country:US
Practice Address - Phone:704-302-9300
Practice Address - Fax:704-302-9301
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25958207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC660003567OtherMEDICARE-RR
NC80105OtherBCBSNC
NC8980105Medicaid
NC1063433456Medicaid
SCN25958Medicaid
NC2074656Medicare PIN
NC202642MMedicare PIN
SCN25958Medicaid
NC1063433456Medicaid