Provider Demographics
NPI:1881649895
Name:SUNGATE MEDICAL LLC
Entity Type:Organization
Organization Name:SUNGATE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTCHKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-459-7800
Mailing Address - Street 1:8711 BURNET RD
Mailing Address - Street 2:SUITE D-45
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7043
Mailing Address - Country:US
Mailing Address - Phone:512-459-7800
Mailing Address - Fax:512-459-7885
Practice Address - Street 1:8711 BURNET RD
Practice Address - Street 2:SUITE D-45
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7043
Practice Address - Country:US
Practice Address - Phone:512-459-7800
Practice Address - Fax:512-459-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0073906332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152618802Medicaid
TX152618801Medicaid
TX531259OtherBCBS
OK200079810AMedicaid
OK200079810AMedicaid
TX531259OtherBCBS
TX=========OtherHUMANA
TX=========OtherHUMANA