1043303548 NPI number — JOSEPH C SULLIVAN III M.D.

Table of content: JOSEPH C SULLIVAN III M.D. (NPI 1043303548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043303548 NPI number — JOSEPH C SULLIVAN III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
JOSEPH
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
III
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:
1043303548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 116700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-6700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-236-5884
Provider Business Mailing Address Fax Number:
904-346-4334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11375 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613-5409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-236-5884
Provider Business Practice Location Address Fax Number:
904-346-4334
Provider Enumeration Date:
10/02/2006

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: 2085N0700X , with the licence number:  052837 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 54994 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 24871 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME160669 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04923068 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051543136 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051543144 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009942662 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009942659 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 199147922A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009942658 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009942660 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051543137 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051543142 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00406959 . This is a "RR MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 117798900 . 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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