Healthcare Provider Details

I. General information

NPI: 1184653669
Provider Name (Legal Business Name): ANDREW SUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 DIXMYTH AVE
CINCINNATI OH
45220
US

IV. Provider business mailing address

4600 WESLEY AVE STE N
CINCINNATI OH
45212-2298
US

V. Phone/Fax

Practice location:
  • Phone: 513-246-7000
  • Fax: 513-246-7590
Mailing address:
  • Phone: 513-246-7800
  • Fax: 513-246-7852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35078633
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200964400
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 2
Identifier7100088000
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer
# 3
Identifier2282408
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: