Provider Demographics
NPI:1235351412
Name:SUNSHINE PEDIATRIC CARE
Entity Type:Organization
Organization Name:SUNSHINE PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MGR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:RUCKER
Authorized Official - Last Name:MIHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-480-1639
Mailing Address - Street 1:P.O BOX 1843
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284
Mailing Address - Country:US
Mailing Address - Phone:941-480-0088
Mailing Address - Fax:941-480-0006
Practice Address - Street 1:145 MIAMI AVE EAST
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285
Practice Address - Country:US
Practice Address - Phone:941-480-0088
Practice Address - Fax:941-480-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0086844173000000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG88986Medicare UPIN
FLG36286Medicare UPIN