Healthcare Provider Details

I. General information

NPI: 1770788770
Provider Name (Legal Business Name): SUNSHINE MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N GRAND AVE SUITE 120
PUEBLO CO
81003-2700
US

IV. Provider business mailing address

1600 N GRAND AVE SUITE 120
PUEBLO CO
81003-2700
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-9292
  • Fax: 719-545-9191
Mailing address:
  • Phone: 719-545-9292
  • Fax: 719-545-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44387
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number44387
License Number StateCO

VIII. Authorized Official

Name: MRS. INDIRA KEDLAYA
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 719-545-9292