Provider Demographics
NPI:1629491642
Name:EAST SUNRISE MEDICAL PLLC
Entity Type:Organization
Organization Name:EAST SUNRISE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LI
Authorized Official - Middle Name:
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-333-5537
Mailing Address - Street 1:6402 8TH AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-4720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6402 8TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-4720
Practice Address - Country:US
Practice Address - Phone:718-333-5537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03391137Medicaid
NY03391137Medicaid