Healthcare Provider Details

I. General information

NPI: 1386817773
Provider Name (Legal Business Name): SUNRISE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3602 CUMBERLAND AVE SUITE B103
MIDDLESBORO KY
40965-2614
US

IV. Provider business mailing address

PO BOX 546
MIDDLESBORO KY
40965-0546
US

V. Phone/Fax

Practice location:
  • Phone: 606-248-6999
  • Fax:
Mailing address:
  • Phone: 606-248-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38144
License Number StateKY

VIII. Authorized Official

Name: DR. WAEL I GHANIM
Title or Position: OWNER
Credential: M.D.
Phone: 606-248-6999