Provider Demographics
NPI:1962969352
Name:SUNNYSIDE MEDICAL
Entity type:Organization
Organization Name:SUNNYSIDE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:504-495-2727
Mailing Address - Street 1:4561 EDFIELD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77051-1909
Mailing Address - Country:US
Mailing Address - Phone:713-425-3772
Mailing Address - Fax:713-425-3772
Practice Address - Street 1:4561 EDFIELD ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77051-1909
Practice Address - Country:US
Practice Address - Phone:713-425-3772
Practice Address - Fax:713-425-3772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine