1952368557 NPI number — JOHN PATRICK SULLIVAN M.D.

Table of content: JOHN PATRICK SULLIVAN M.D. (NPI 1952368557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952368557 NPI number — JOHN PATRICK SULLIVAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
JOHN
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952368557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1218 S BROADWAY
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40504-2759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-219-0542
Provider Business Mailing Address Fax Number:
859-219-9433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 W BARAGA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-4550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-449-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  39464 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64098940 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112126800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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