1912957697 NPI number — SUNRISE MEDICAL GROUP INC

Table of content: (NPI 1912957697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912957697 NPI number — SUNRISE MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNRISE MEDICAL GROUP INC
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:
1912957697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6245 N FEDERAL HWY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-1998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-956-1966
Provider Business Mailing Address Fax Number:
954-745-0501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4925 SHERIDAN ST
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-2829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-981-3850
Provider Business Practice Location Address Fax Number:
954-981-3889
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZYGALA
Authorized Official First Name:
GIOVANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
954-956-1966

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 258676203 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258676205 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258676201 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258676204 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258676200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258676202 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258676206 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009746100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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