Basic Information
Provider Information | |||||||||
NPI: | 1659541118 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUN HEALTH MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUN HEALTH GERIATRIC PHYSICIAN ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1278 | ||||||||
Address2: | ATTN: MINDY OGDEN | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853721278 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235445075 | ||||||||
FaxNumber: | 6235445093 | ||||||||
Practice Location | |||||||||
Address1: | 10515 W SANTA FE DR | ||||||||
Address2: |   | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853513020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6238157661 | ||||||||
FaxNumber: | 6238152981 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2008 | ||||||||
LastUpdateDate: | 03/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SELLNER | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6238766616 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUN HEALTH CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207RG0300X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.