MEDICARE: GEORGE SUN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00180554	OTHER	IL	RR MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	207988	OTHER	IL	GROUP
2	CH4443	OTHER	IL	RR GROUP NUMBER

General Provider Information

NPI Number	:	1053350173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE SUN MD

Provider Business Mailing Address
First Line	:	430 N PLEASANT AVE
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3006
Country	:	US
Telephone Number	:	618-436-8350
Fax Number	:	618-532-9347

Provider Business Practice Location Address
First Line	:	430 N PLEASANT AVE
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3006
Country	:	US
Telephone Number	:	618-436-8350
Fax Number	:	618-532-9347

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	11/27/2007

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Directions to “ GEORGE SUN MD” Practice Location

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