Provider Demographics
NPI:1710347596
Name:SUNRISE ADVANCED PEDIATRICS PLLC
Entity Type:Organization
Organization Name:SUNRISE ADVANCED PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PEARSON
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-780-7248
Mailing Address - Street 1:12274 BANDERA RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4385
Mailing Address - Country:US
Mailing Address - Phone:210-780-7248
Mailing Address - Fax:210-780-7251
Practice Address - Street 1:12274 BANDERA RD
Practice Address - Street 2:SUITE 104
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4385
Practice Address - Country:US
Practice Address - Phone:210-780-7248
Practice Address - Fax:210-780-7251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX357756101Medicaid
TX357756101Medicaid