1245247501 NPI number — GAIL T SULLIVAN MD

Table of content: GAIL T SULLIVAN MD (NPI 1245247501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245247501 NPI number — GAIL T SULLIVAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
GAIL
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1245247501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 820933
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-0933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-602-8900
Provider Business Mailing Address Fax Number:
215-602-8904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9331 OLD BUSTLETON AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19115-4204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-602-8900
Provider Business Practice Location Address Fax Number:
215-602-8904
Provider Enumeration Date:
08/01/2006

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: 207V00000X , with the licence number:  MD054949L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: MD-054949-L , 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: 1007278000 . This is a "TPI MEDICAID GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 597586 . This is a "TPI GROUP MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001534913 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD4829 . This is a "TPI RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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