Provider Demographics
NPI:1730407875
Name:LUNDQUIST, ROGER ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
Last Name:LUNDQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4201 W MEDICAL CENTER DR
Mailing Address - Street 2:ATTN: E. PETERS MOB B107
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8409
Mailing Address - Country:US
Mailing Address - Phone:815-759-8147
Mailing Address - Fax:815-759-8154
Practice Address - Street 1:11650 SOUTH ROUTE 47
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-052927208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL962341Medicare PIN