Provider Demographics
NPI:1316910037
Name:SUNDT, THORALF M III (MD)
Entity type:Individual
Prefix:
First Name:THORALF
Middle Name:M
Last Name:SUNDT
Suffix:III
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 1:55 FRUIT STREET
Mailing Address - Street 2:COX 630
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-643-9745
Mailing Address - Fax:617-726-5804
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-643-9745
Practice Address - Fax:617-726-5804
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56651208G00000X, 208600000X
MN44107208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN023740000Medicaid
MN023740000Medicaid
G16346Medicare UPIN
MN780002032Medicare ID - Type UnspecifiedRAILROAD