Healthcare Provider Details

I. General information

NPI: 1720452584
Provider Name (Legal Business Name): SUNRISE DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 03/01/2019
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: 251-544-6410
  • Fax: 251-544-6411
Mailing address:
  • Phone: 251-544-6410
  • Fax: 251-544-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1152005
License Number StateAL

VIII. Authorized Official

Name: DR. SCOTT RUSSELL FREEMAN
Title or Position: PARTNER
Credential: M.D
Phone: 251-544-6410