Provider Demographics
NPI:1205263290
Name:SUNRISE PAIN AND REHABILITATION MEDICINE PC
Entity type:Organization
Organization Name:SUNRISE PAIN AND REHABILITATION MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-763-1091
Mailing Address - Street 1:4602 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1317
Mailing Address - Country:US
Mailing Address - Phone:347-763-1091
Mailing Address - Fax:347-763-1092
Practice Address - Street 1:4602 6TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1317
Practice Address - Country:US
Practice Address - Phone:347-763-1091
Practice Address - Fax:347-763-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2030351273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01793177Medicaid
NY01793177Medicaid