=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144452079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE PEDIATRICS, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2009
-----------------------------------------------------
Last Update Date | 10/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 S LINDSAY RD STE # 126
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-1506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-892-3500
-----------------------------------------------------
Fax | 480-664-3632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4100 S LINDSAY RD STE # 126
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-1506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-892-3500
-----------------------------------------------------
Fax | 480-664-3632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. SANJAY J SHAH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 480-892-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 34629
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------