Provider Demographics
NPI:1871824391
Name:SUNRISE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:SUNRISE MEDICAL CLINIC, LLC
Other - Org Name:VITALIS O. OJIEGBE, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAGDALENE
Authorized Official - Middle Name:
Authorized Official - Last Name:OJIEGBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-220-3500
Mailing Address - Street 1:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20768-1527
Mailing Address - Country:US
Mailing Address - Phone:301-220-9500
Mailing Address - Fax:301-982-0321
Practice Address - Street 1:6201 GREENBELT RD
Practice Address - Street 2:SUITE M-17
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2354
Practice Address - Country:US
Practice Address - Phone:301-220-9500
Practice Address - Fax:301-982-0321
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITALIS O. OJIEGBE, MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11328638OtherCAQH
MD027374100Medicaid
MD027374100Medicaid
MD11328638OtherCAQH
MD027374100Medicaid