Healthcare Provider Details

I. General information

NPI: 1114291721
Provider Name (Legal Business Name): SUNNYSIDE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1182 STUYVESANT AVE
IRVINGTON NJ
07111-1057
US

IV. Provider business mailing address

1182 STUYVESANT AVE
IRVINGTON NJ
07111-1057
US

V. Phone/Fax

Practice location:
  • Phone: 973-399-0571
  • Fax: 973-399-1555
Mailing address:
  • Phone: 973-399-0571
  • Fax: 973-399-1555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMA06019
License Number StateNJ

VIII. Authorized Official

Name: JUSTINA U ANYANWU
Title or Position: OWNER
Credential: MD
Phone: 973-399-0571