Provider Demographics
NPI:1336107242
Name:ROBERT D SULLIVAN MD PC
Entity Type:Organization
Organization Name:ROBERT D SULLIVAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-944-2015
Mailing Address - Street 1:2323 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1937
Mailing Address - Country:US
Mailing Address - Phone:814-944-2015
Mailing Address - Fax:814-944-6638
Practice Address - Street 1:2323 BROAD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1937
Practice Address - Country:US
Practice Address - Phone:814-944-2015
Practice Address - Fax:814-944-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-032190-E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA118929OtherMEDICARE GROUP
PA306919OtherHEALTHASSURANCE
PA131605OtherKEYSTONE HEALTH PLAN WEST
PA131605OtherHIGHMARK BLUECROSS BLUESH
PA14593OtherHEALTHAMERICA
PA29300OtherGEISINGER HEALTH PLAN
PA1017317OtherGATEWAY HEALTH PLAN
PA0009710480002Medicaid
PA131605OtherHIGHMARK BLUECROSS BLUESH
PA1017317OtherGATEWAY HEALTH PLAN