Basic Information
| Provider Information | |||||||||
| NPI: | 1033151428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | .SUNSTAR GERIATRICS HEALTHCARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S AUSTIN AVE | ||||||||
| Address2: | SUITE 1320 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786265610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128689078 | ||||||||
| FaxNumber: | 5128190646 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S AUSTIN AVE | ||||||||
| Address2: | SUITE 1320 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786265610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128689078 | ||||||||
| FaxNumber: | 5128190646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 04/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHOI | ||||||||
| AuthorizedOfficialFirstName: | MARYANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5128689078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | K9039 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 173285101 | 05 | TX | MEDICAID |