Provider Demographics
NPI:1275607624
Name:SULLIVAN, RICHARD JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
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:PO BOX 4440
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13442-4440
Mailing Address - Country:US
Mailing Address - Phone:315-336-3400
Mailing Address - Fax:315-336-2691
Practice Address - Street 1:7904 TURIN RD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-1933
Practice Address - Country:US
Practice Address - Phone:315-336-3400
Practice Address - Fax:315-336-2691
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00604215Medicaid
NY00604215Medicaid
30193BMedicare PIN