Provider Demographics
NPI:1033187828
Name:SULLIVAN, PAMELA ANN (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:ANN
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1000 EDGEWATER POINTE
Mailing Address - Street 2:SUITE - 200
Mailing Address - City:LAKE ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367
Mailing Address - Country:US
Mailing Address - Phone:636-561-8088
Mailing Address - Fax:636-561-1405
Practice Address - Street 1:1000 EDGEWATER POINTE
Practice Address - Street 2:SUITE: 200
Practice Address - City:LAKE ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-561-8088
Practice Address - Fax:636-561-1405
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106412207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208094821Medicaid
G71271Medicare UPIN
MO208094821Medicaid