1164419131 NPI number — BRIAN P SULLIVAN M.D.

Table of content: BRIAN P SULLIVAN M.D. (NPI 1164419131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164419131 NPI number — BRIAN P SULLIVAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
BRIAN
Provider Middle Name:
P
Provider Name Prefix Text:
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:
1164419131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 ABBEYVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17603-4603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-291-5991
Provider Business Mailing Address Fax Number:
717-291-5806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 ABBEYVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17603-4603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-291-5991
Provider Business Practice Location Address Fax Number:
717-291-5806
Provider Enumeration Date:
10/04/2005

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:  MD423238 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P006174 . This is a "GATEWAY HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7996672 . This is a "AETNA NON-HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1010754010001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1622688 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1086443 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 107749 S1QD . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: I07849 . This is a "HEALTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50036997 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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