Provider Demographics
NPI:1720452584
Name:SUNRISE DERMATOLOGY
Entity type:Organization
Organization Name:SUNRISE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-544-6410
Mailing Address - Street 1:70 MIDTOWN PARK E
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-4140
Mailing Address - Country:US
Mailing Address - Phone:251-544-6410
Mailing Address - Fax:251-544-6411
Practice Address - Street 1:70 MIDTOWN PARK E
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-4140
Practice Address - Country:US
Practice Address - Phone:251-544-6410
Practice Address - Fax:251-544-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1152005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty