Provider Demographics
NPI:1548362775
Name:GUNDERSEN, KARL RAYMOND (MD)
Entity type:Individual
Prefix:MR
First Name:KARL
Middle Name:RAYMOND
Last Name:GUNDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 MADISON AVE
Mailing Address - Street 2:STE 405
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040
Mailing Address - Country:US
Mailing Address - Phone:618-876-0653
Mailing Address - Fax:618-876-0654
Practice Address - Street 1:2120 MADISON AVE
Practice Address - Street 2:STE 405
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040
Practice Address - Country:US
Practice Address - Phone:618-876-0653
Practice Address - Fax:618-876-0654
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361051022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205739907OtherMEDICAID
IL036105102Medicaid
H47389Medicare UPIN
IL036105102Medicaid