Provider Demographics
NPI:1134458839
Name:JOHN E SULLIVAN MD PA
Entity Type:Organization
Organization Name:JOHN E SULLIVAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-365-2918
Mailing Address - Street 1:1880 ARLINGTON ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3518
Mailing Address - Country:US
Mailing Address - Phone:941-365-2918
Mailing Address - Fax:941-366-1658
Practice Address - Street 1:1880 ARLINGTON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3524
Practice Address - Country:US
Practice Address - Phone:941-365-2918
Practice Address - Fax:941-366-1658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045524500Medicaid
FL58173Medicare PIN
FL045524500Medicaid