1215106067 NPI number — MR. STEVEN W SULLIVAN PA-C

Table of content: MR. STEVEN W SULLIVAN PA-C (NPI 1215106067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215106067 NPI number — MR. STEVEN W SULLIVAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
STEVEN
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1215106067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 S. CRAIN HIGHWAY
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
GLEN BURNIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-768-5050
Provider Business Mailing Address Fax Number:
410-768-7830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 CRAIN HWY S
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-5577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-768-5050
Provider Business Practice Location Address Fax Number:
410-768-7830
Provider Enumeration Date:
02/26/2008

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: 363AS0400X , with the licence number:  C0003015 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 246492 . This is a "JHHC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9630991 . This is a "AETNA PPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 8738246 . This is a "AETNA HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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