Healthcare Provider Details

I. General information

NPI: 1235351412
Provider Name (Legal Business Name): SUNSHINE PEDIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MIAMI AVE EAST
VENICE FL
34285
US

IV. Provider business mailing address

P.O BOX 1843
VENICE FL
34284
US

V. Phone/Fax

Practice location:
  • Phone: 941-480-0088
  • Fax: 941-480-0006
Mailing address:
  • Phone: 941-480-0088
  • Fax: 941-480-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number0086844
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN RUCKER MIHM
Title or Position: PHYSICIAN/MGR
Credential: M.D.
Phone: 941-480-1639