1841292562 NPI number — MITCHELL SULLIVAN MD

Table of content: MITCHELL SULLIVAN MD (NPI 1841292562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841292562 NPI number — MITCHELL SULLIVAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
MITCHELL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1841292562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 83
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNDONVILLE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05851-0083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-748-9501
Provider Business Mailing Address Fax Number:
802-748-3420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 INDUSTRIAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNDONVILLE
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05851-4511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-748-9501
Provider Business Practice Location Address Fax Number:
802-748-3420
Provider Enumeration Date:
08/12/2005

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: 207Q00000X , with the licence number:  9367 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 042-0012982 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 160094 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0106084YPNH01 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 5830418 . This is a "AETNA GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9367 . This is a "STATE LICENSE #" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30008999 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 930044719 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3073723 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".