Provider Demographics
NPI:1194775445
Name:LUNDEEN, BRIAN E (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:LUNDEEN
Suffix:
Gender:
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:414-744-6589
Practice Address - Fax:414-747-8848
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0885722085P0229X, 2085R0202X
WI305282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-088572Medicaid
WI31882600Medicaid
IL202926OtherGROUP PTAN
ILK12662Medicare PIN
ILK13137Medicare PIN
WI31882600Medicaid
WIF42449Medicare UPIN
IL036-088572Medicaid