Provider Demographics
NPI:1104807262
Name:SUN MEDICAL
Entity type:Organization
Organization Name:SUN MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-422-8185
Mailing Address - Street 1:1880 N 725 W
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-9002
Mailing Address - Country:US
Mailing Address - Phone:317-422-8185
Mailing Address - Fax:317-422-4722
Practice Address - Street 1:1880 N 725 W
Practice Address - Street 2:
Practice Address - City:BARGERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46106-9002
Practice Address - Country:US
Practice Address - Phone:317-422-8185
Practice Address - Fax:317-422-4722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200160630AMedicaid
IN=========OtherTAX ID
IN200160630AMedicaid