Basic Information
| Provider Information | |||||||||
| NPI: | 1912177478 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUN HEALTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | SUN HEALTH PAIN MANAGEMENT CENTER | ||||||||
| 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: | 13203 N 103RD AVE | ||||||||
| Address2: | SUITE H5 | ||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238756570 | ||||||||
| FaxNumber: | 6239720049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | SELLNER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6238766616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUN HEALTH CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.