Provider Demographics
NPI:1699795179
Name:SUNRISE UROLOGY PC
Entity type:Organization
Organization Name:SUNRISE UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-507-9600
Mailing Address - Street 1:PO BOX 2464
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-2464
Mailing Address - Country:US
Mailing Address - Phone:480-507-9600
Mailing Address - Fax:480-507-9610
Practice Address - Street 1:3303 S LINDSAY RD
Practice Address - Street 2:STE 121
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-1503
Practice Address - Country:US
Practice Address - Phone:480-507-9600
Practice Address - Fax:480-507-9610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31442208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ778582Medicaid
AZH81520Medicare UPIN
AZ778582Medicaid