Provider Demographics
NPI:1275810780
Name:SUNNYSIDE PEDIATRICS
Entity Type:Organization
Organization Name:SUNNYSIDE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRABHUDEV
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-715-4808
Mailing Address - Street 1:600 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4214
Mailing Address - Country:US
Mailing Address - Phone:770-233-4668
Mailing Address - Fax:678-866-2636
Practice Address - Street 1:600 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-233-4668
Practice Address - Fax:678-866-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055272208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA785450399CMedicaid