1194781617 NPI number — WENDY S. SULLIVAN P.A.

Table of content: ASHLEY HER (NPI 1699422998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194781617 NPI number — WENDY S. SULLIVAN P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
WENDY
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

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:
1194781617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 CROSSROADS DR
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-5421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-738-2872
Provider Business Mailing Address Fax Number:
443-738-2713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6820 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21237-4352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-391-6131
Provider Business Practice Location Address Fax Number:
410-391-6144
Provider Enumeration Date:
04/24/2006

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: 363A00000X , with the licence number:  0110 002181 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: C0002516 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010234085 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 541203530 . This is a "TAS IDENTIFICATION NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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