Provider Demographics
NPI:1174818355
Name:SULLIVAN, JILL MAXWELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:MAXWELL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GROVE RD
Mailing Address - Street 2:GHS MED-PEDS RESIDENCY
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5611
Mailing Address - Country:US
Mailing Address - Phone:864-455-7844
Mailing Address - Fax:864-455-7848
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:GHS MED-PEDS RESIDENCY
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-7844
Practice Address - Fax:864-455-7848
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33553207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics