Provider Demographics
NPI:1083866040
Name:SUNNYSIDE COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:SUNNYSIDE COMMUNITY HOSPITAL
Other - Org Name:SUNNYSIDE ENT, SUNNYSIDE BONE AND JOINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PFS-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-837-1617
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0719
Mailing Address - Country:US
Mailing Address - Phone:509-837-1617
Mailing Address - Fax:509-837-1714
Practice Address - Street 1:2925 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8931
Practice Address - Country:US
Practice Address - Phone:509-837-1617
Practice Address - Fax:509-837-1714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60307626207X00000X
WAMD60030905207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8527194Medicaid
WA7144421Medicaid
WA8527194Medicaid