Provider Demographics
NPI:1114291721
Name:SUNNYSIDE PEDIATRICS LLC
Entity Type:Organization
Organization Name:SUNNYSIDE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINA
Authorized Official - Middle Name:U
Authorized Official - Last Name:ANYANWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-399-0571
Mailing Address - Street 1:1182 STUYVESANT AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1057
Mailing Address - Country:US
Mailing Address - Phone:973-399-0571
Mailing Address - Fax:973-399-1555
Practice Address - Street 1:1182 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1057
Practice Address - Country:US
Practice Address - Phone:973-399-0571
Practice Address - Fax:973-399-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06019261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7191308Medicaid