1790733822 NPI number — DR. SCOTT J SULLIVAN M.D.

Table of content: DR. SCOTT J SULLIVAN M.D. (NPI 1790733822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790733822 NPI number — DR. SCOTT J SULLIVAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
SCOTT
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
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:
1790733822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49 LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06830-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-861-2381
Provider Business Mailing Address Fax Number:
203-983-3318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06830-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-869-6220
Provider Business Practice Location Address Fax Number:
203-869-2672
Provider Enumeration Date:
05/04/2006

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:  039001 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001390012 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120127300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".