1174705628 NPI number — VINCENT E. SULLIVAN MD PC

Table of content: (NPI 1174705628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174705628 NPI number — VINCENT E. SULLIVAN MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINCENT E. SULLIVAN MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1174705628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19878 SAINT JOSEPH DR
Provider Second Line Business Mailing Address:
P.O. BOX 160
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52544-8850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-437-1576
Provider Business Mailing Address Fax Number:
641-437-4205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19878 SAINT JOSEPH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52544-8850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-437-1576
Provider Business Practice Location Address Fax Number:
641-437-4205
Provider Enumeration Date:
11/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-437-1576

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  18213 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0186270 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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