1194285544 NPI number — JINGSHUO SUN MD

Table of content: TAYLIN TYLER (NPI 1740925890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194285544 NPI number — JINGSHUO SUN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUN
Provider First Name:
JINGSHUO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUN
Provider Other First Name:
DEREK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1194285544
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 725
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOPERSTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13326-0725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-547-3456
Provider Business Mailing Address Fax Number:
607-547-6612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 FRANCIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02115-6106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-732-5500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 35.152249 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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