Provider Demographics
NPI:1871762625
Name:SUNROSE ANESTHESIA PLLC
Entity type:Organization
Organization Name:SUNROSE ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BOELDRIDGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-974-9571
Mailing Address - Street 1:12361 W BOLA DR STE 107
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:623-974-9571
Mailing Address - Fax:623-974-9741
Practice Address - Street 1:12361 W BOLA DR STE 107
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:623-974-9571
Practice Address - Fax:623-974-9741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30909207L00000X
208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ228037Medicaid