Provider Demographics
NPI:1780717207
Name:SUNNYSIDE FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:SUNNYSIDE FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTION/BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-837-6681
Mailing Address - Street 1:2240 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2487
Mailing Address - Country:US
Mailing Address - Phone:509-837-6681
Mailing Address - Fax:509-839-0075
Practice Address - Street 1:2240 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2487
Practice Address - Country:US
Practice Address - Phone:509-837-6681
Practice Address - Fax:509-839-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8935331OtherCRIME VICTIMS NUMBER
WA0146394OtherL&I NUMBER
WA9616897Medicaid
WA0052792OtherL&I NUMBER
WA1057496Medicaid
WA7081540Medicaid
WA8264582Medicaid
WA0146393OtherL&I NUMBER
WA112305OtherL&I GROUP NUMBER
WA8935331OtherCRIME VICTIMS NUMBER
WA9616897Medicaid
WA0052792OtherL&I NUMBER
WAP83588Medicare UPIN
WAE08911Medicare ID - Type Unspecified
WA7081540Medicaid