Provider Demographics
NPI:1023000700
Name:SULLIVAN, PAUL MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MARK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19454 TRAMORE LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8594
Mailing Address - Country:US
Mailing Address - Phone:708-460-8688
Mailing Address - Fax:708-460-9272
Practice Address - Street 1:10751 W 143RD ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-1900
Practice Address - Country:US
Practice Address - Phone:708-460-8688
Practice Address - Fax:708-460-9272
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7806111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2645935OtherAETNA HMO
IL7199255OtherNON-HMO
ILL85064Medicare ID - Type Unspecified
U78358Medicare UPIN