Basic Information
| Provider Information | |||||||||
| NPI: | 1124107446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE MEDICAL GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 CAMINO DE VIDA | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 CAMINO DE VIDA | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5754724311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 6794 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1124107446 | 01 | NM | GROUP NPI | OTHER | 600521016 | 01 | MEDICARE GROUP ID | OTHER | 00074686 | 05 | NM | MEDICAID | 6794 | 01 | NM | NM HEALTH DEPT. NO. | OTHER |