Provider Demographics
NPI:1154591477
Name:EDWARD G. LUNDBLAD, MD, PC
Entity type:Organization
Organization Name:EDWARD G. LUNDBLAD, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:LUNDBLAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-671-8487
Mailing Address - Street 1:579 S. LAREDO CIRCLE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017
Mailing Address - Country:US
Mailing Address - Phone:303-671-8487
Mailing Address - Fax:303-671-5160
Practice Address - Street 1:579 S. LAREDO CIRCLE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80017
Practice Address - Country:US
Practice Address - Phone:303-671-8487
Practice Address - Fax:303-671-5160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02152394Medicaid
CO02152394Medicaid
COC55951Medicare PIN