Healthcare Provider Details

I. General information

NPI: 1003192915
Provider Name (Legal Business Name): GOLDEN SUN BEAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13083 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0926
US

IV. Provider business mailing address

3 HAWTHORN PKWY SUITE 410
VERNON HILLS IL
60061-1446
US

V. Phone/Fax

Practice location:
  • Phone: 813-971-3064
  • Fax: 813-977-3607
Mailing address:
  • Phone: 847-949-3845
  • Fax: 866-408-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES HILGER
Title or Position: CHIEF ACCOUNTING OFFICER
Credential:
Phone: 253-280-9501