Provider Demographics
NPI:1912957697
Name:SUNRISE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SUNRISE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GIOVANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZYGALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-956-1966
Mailing Address - Street 1:6245 N FEDERAL HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1998
Mailing Address - Country:US
Mailing Address - Phone:954-956-1966
Mailing Address - Fax:954-745-0501
Practice Address - Street 1:4925 SHERIDAN ST
Practice Address - Street 2:200
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2829
Practice Address - Country:US
Practice Address - Phone:954-981-3850
Practice Address - Fax:954-981-3889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSAL MEDICAL CONCEPTS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258676203Medicaid
FL258676205Medicaid
FL258676201Medicaid
FL258676204Medicaid
FL258676200Medicaid
FL258676202Medicaid
FL258676206Medicaid
FLK1581Medicare ID - Type Unspecified
FL258676204Medicaid