Basic Information
| Provider Information | |||||||||
| NPI: | 1083866040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNNYSIDE COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNNYSIDE ENT, SUNNYSIDE BONE AND JOINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 719 | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989440719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371617 | ||||||||
| FaxNumber: | 5098371714 | ||||||||
| Practice Location | |||||||||
| Address1: | 2925 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989448931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371617 | ||||||||
| FaxNumber: | 5098371714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHUTT | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PFS-MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5098371617 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD60307626 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | MD60030905 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 8527194 | 05 | WA | MEDICAID | 7144421 | 05 | WA | MEDICAID |