Provider Demographics
NPI:1326490889
Name:SUNDANCE PHYSICIAN SERVICES, INC
Entity Type:Organization
Organization Name:SUNDANCE PHYSICIAN SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-727-3530
Mailing Address - Street 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3060
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:7500 RIALTO BLVD STE 1-140
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8534
Practice Address - Country:US
Practice Address - Phone:512-730-3060
Practice Address - Fax:888-730-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36756901Medicaid