Provider Demographics
NPI:1386758605
Name:LUNDERGAN, MICHAEL SHANE (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:LUNDERGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HOLT DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-1670
Mailing Address - Country:US
Mailing Address - Phone:812-265-6141
Mailing Address - Fax:812-265-6318
Practice Address - Street 1:110 HOLT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-1670
Practice Address - Country:US
Practice Address - Phone:812-265-6141
Practice Address - Fax:812-265-6318
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5462620OtherAETNA PROVIDER ID
IN000000210324OtherANTHEM PROVIDER ID
IN192150Medicare ID - Type Unspecified