Basic Information
| Provider Information | |||||||||
| NPI: | 1528367646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE ANESTHESIA & PAIN MANAGEMENT, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1917 | ||||||||
| Address2: | |||||||||
| City: | SPRINGERVILLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859381917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284683132 | ||||||||
| FaxNumber: | 8885891943 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 S MOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGERVILLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859385104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283330562 | ||||||||
| FaxNumber: | 9283337157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9284683132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | CRNA0632 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 464411 | 05 | AZ | MEDICAID |