1295736155 NPI number — MICHAEL J. SULLIVAN MD

Table of content: RONALD M. REILLY M.D. (NPI 1194725465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295736155 NPI number — MICHAEL J. SULLIVAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL J. SULLIVAN MD
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:
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:
1295736155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOLANA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92075-0638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-692-3977
Provider Business Mailing Address Fax Number:
619-692-4160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 EL CAJON BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-692-3977
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
619-692-3977

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  B1992003399 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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