Basic Information
| Provider Information | |||||||||
| NPI: | 1164598421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBURY CLINIC COMPANY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 FRANKLIN RD | ||||||||
| Address2: | #135A-333 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370273280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154653152 | ||||||||
| FaxNumber: | 6154653017 | ||||||||
| Practice Location | |||||||||
| Address1: | 337 ARCH ST | ||||||||
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| City: | SUNBURY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178012212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702860303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NEWSOME | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6154653152 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.