1710347596 NPI number — SUNRISE ADVANCED PEDIATRICS PLLC

Table of content: (NPI 1710347596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710347596 NPI number — SUNRISE ADVANCED PEDIATRICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNRISE ADVANCED PEDIATRICS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710347596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12274 BANDERA RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
HELOTES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78023-4385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-780-7248
Provider Business Mailing Address Fax Number:
210-780-7251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12274 BANDERA RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HELOTES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78023-4385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-780-7248
Provider Business Practice Location Address Fax Number:
210-780-7251
Provider Enumeration Date:
03/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
PEARSON
Authorized Official Title or Position:
AUTHORIZED REP/OWNER
Authorized Official Telephone Number:
210-780-7248

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0207X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 357756101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com