Provider Demographics
NPI:1306023361
Name:SUNSHINE MEDICAL, LLC
Entity Type:Organization
Organization Name:SUNSHINE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAWANDUS
Authorized Official - Middle Name:LOVETT
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:615-942-9271
Mailing Address - Street 1:PO BOX 160441
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37216-0441
Mailing Address - Country:US
Mailing Address - Phone:615-942-9271
Mailing Address - Fax:
Practice Address - Street 1:801 E OLD HICKORY BLVD
Practice Address - Street 2:STE 150
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4169
Practice Address - Country:US
Practice Address - Phone:615-942-9271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicare UPIN