Basic Information
| Provider Information | |||||||||
| NPI: | 1689843872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUN HEALTH MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | SUN HEALTH DEL E. WEBB HEALTH CENTER OF WICKENBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 1395 W WICKENBURG WAY | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853904231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233889957 | ||||||||
| FaxNumber: | 9286847457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | BROSOR | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6235445079 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUN HEALTH CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.