Healthcare Provider Details

I. General information

NPI: 1649562521
Provider Name (Legal Business Name): SUNRISE DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MIDTOWN PARK E
MOBILE AL
36606-4140
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: 251-289-1786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD30842
License Number StateAL

VIII. Authorized Official

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