Healthcare Provider Details

I. General information

NPI: 1871762625
Provider Name (Legal Business Name): SUNROSE ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12361 W BOLA DR STE 107
SURPRISE AZ
85378-9021
US

IV. Provider business mailing address

12361 W BOLA DR STE 107
SURPRISE AZ
85378-9021
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-9571
  • Fax: 623-974-9741
Mailing address:
  • Phone: 623-974-9571
  • Fax: 623-974-9741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number30909
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BOELDRIDGE MCCLAIN
Title or Position: SOLE MEMBER
Credential: M.D.
Phone: 623-974-9571