1376613737 NPI number — DR. GERALD EUGENE SULLIVAN GERALD SULLIVAN

Table of content: DR. GERALD EUGENE SULLIVAN GERALD SULLIVAN (NPI 1376613737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376613737 NPI number — DR. GERALD EUGENE SULLIVAN GERALD SULLIVAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
GERALD
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
GERALD SULLIVAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SULLIVAN
Provider Other First Name:
GERALD
Provider Other Middle Name:
EUGENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376613737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
730 FAIRVIEW AVE
Provider Second Line Business Mailing Address:
SUITE B1
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42101-2367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-781-3321
Provider Business Mailing Address Fax Number:
270-781-9121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
SUITE B1
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42101-2367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-781-3321
Provider Business Practice Location Address Fax Number:
270-781-9121
Provider Enumeration Date:
11/09/2006

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: 207W00000X , with the licence number:  15078 , 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)





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