Provider Demographics
NPI:1770788770
Name:SUNSHINE MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:SUNSHINE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEDLAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-545-9292
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-545-9292
Mailing Address - Fax:719-545-9191
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-545-9292
Practice Address - Fax:719-545-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44387207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PE2582OtherRR MEDICARE
CO73637556Medicaid
COC808622Medicare PIN
CO73637556Medicaid