1760508329 NPI number — JULIA W SULLIVAN CRNA

Table of content: JULIA W SULLIVAN CRNA (NPI 1760508329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760508329 NPI number — JULIA W SULLIVAN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
JULIA
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1760508329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 STADIUM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26506-7911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-346-9400
Provider Business Mailing Address Fax Number:
304-720-8461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 J D ANDERSON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-346-9400
Provider Business Practice Location Address Fax Number:
304-345-7320
Provider Enumeration Date:
03/22/2007

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: 367500000X , with the licence number:  47812 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 412266600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1073294 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1019415650001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2742198 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810008943 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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