1780717207 NPI number — SUNNYSIDE FAMILY MEDICINE, PC

Table of content: (NPI 1780717207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780717207 NPI number — SUNNYSIDE FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNNYSIDE FAMILY MEDICINE, PC
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:
1780717207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2240 E LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98944-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-837-6681
Provider Business Mailing Address Fax Number:
509-839-0075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2240 E LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944-2487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-837-6681
Provider Business Practice Location Address Fax Number:
509-839-0075
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MEDELEZ
Authorized Official First Name:
OLGA
Authorized Official Middle Name:
Authorized Official Title or Position:
RECEPTION/BILLING
Authorized Official Telephone Number:
509-837-6681

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OP00001175 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8935331 . This is a "CRIME VICTIMS NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0146394 . This is a "L&I NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9616897 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0052792 . This is a "L&I NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1057496 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7081540 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8264582 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0146393 . This is a "L&I NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 112305 . This is a "L&I GROUP NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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