| Entity Name: | MAURI G. LUNDERMAN, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 22 Aug 1997 (27 years ago) |
| Document Number: | P97000073143 |
| FEI/EIN Number | 593464528 |
| Address: | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL, 32547, US |
| Mail Address: | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL, 32547, US |
| ZIP code: | 32547 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1902839798 | 2006-07-08 | 2010-02-03 | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL, 325471221, US | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL, 325471221, US | |||||||||||||||||||||||||
|
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| Phone | +1 850-864-3232 |
| Fax | 8508645220 |
Authorized person
| Name | DR. MAURI GLENN LUNDERMAN |
| Role | OWNER/PHYSICIAN |
| Phone | 8508643232 |
Taxonomy
| Taxonomy Code | 208600000X - Surgery Physician |
| License Number | ME64728 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 375781100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| LUNDERMAN MAURI G | Agent | 1775 LEWIS TURNER BLVD, FORT WALTON BEACH, FL, 32547 |
| Name | Role | Address |
|---|---|---|
| LUNDERMAN MAURI G | Director | 211 MOONEY RD, FORT WALTON BEACH, FL, 32547 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2020-05-04 | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL 32547 | No data |
| CHANGE OF MAILING ADDRESS | 2020-05-04 | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL 32547 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-05-04 | 1775 LEWIS TURNER BLVD, SUITE 102, FORT WALTON BEACH, FL 32547 | No data |
| REGISTERED AGENT NAME CHANGED | 2013-04-30 | LUNDERMAN, MAURI G | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-01 |
| ANNUAL REPORT | 2023-04-17 |
| ANNUAL REPORT | 2022-04-22 |
| ANNUAL REPORT | 2021-04-23 |
| ANNUAL REPORT | 2020-05-04 |
| ANNUAL REPORT | 2019-04-22 |
| ANNUAL REPORT | 2018-04-24 |
| ANNUAL REPORT | 2017-04-20 |
| ANNUAL REPORT | 2016-03-31 |
| ANNUAL REPORT | 2015-04-22 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
