1871764779 NPI number — DR. GLENN R SULLIVAN PH.D.

Table of content: DR. GLENN R SULLIVAN PH.D. (NPI 1871764779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871764779 NPI number — DR. GLENN R SULLIVAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
GLENN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1871764779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 COLSTON PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24450-1812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-463-2080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 CROSSING LN STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24450-6354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-463-2080
Provider Business Practice Location Address Fax Number:
540-464-7648
Provider Enumeration Date:
03/18/2008

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: 103TC0700X , with the licence number:  0810003867 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1103398805 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 923366841 . This is a "HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 336-841 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: SC0001096 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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