Healthcare Provider Details

I. General information

NPI: 1538630751
Provider Name (Legal Business Name): SUNRISE DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8832 US HWY 90
DAPHNE AL
36526
US

IV. Provider business mailing address

70 MIDTOWN PARK E
MOBILE AL
36606-4140
US

V. Phone/Fax

Practice location:
  • Phone: 251-289-1786
  • Fax:
Mailing address:
  • Phone: 251-544-6407
  • Fax: 251-544-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH WIERSZALOWSKI
Title or Position: ADMINISTRATOR
Credential:
Phone: 251-544-6407