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General NPI Number Information
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NPI Number | 1962969352
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Entity Type | Organization
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Legal Business Name | SUNNYSIDE MEDICAL
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Dates
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Enumeration Date | 02/21/2019
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Last Update Date | 02/21/2019
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Provider Practice Location Address
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Address Line | 4561 EDFIELD ST
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City | HOUSTON
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State | TX
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Zip | 77051-1909
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Country | US
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Telephone | 713-425-3772
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Fax | 713-425-3772
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Provider Business Mailing Address
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Address Line | 4561 EDFIELD ST
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City | HOUSTON
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State | TX
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Zip | 77051-1909
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Country | US
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Telephone | 713-425-3772
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Fax | 713-425-3772
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Authorized Official
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Title or Position | CONTRACT ADMINISTRATOR
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Name | MR. RONELL WILLIAMS JR.
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Credential |
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Telephone | 504-495-2727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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