Provider Demographics
NPI:1356314306
Name:SULLIVAN, PAMELA J (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:J
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 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4199
Mailing Address - Country:US
Mailing Address - Phone:304-623-3461
Mailing Address - Fax:302-623-7666
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-4199
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:304-623-7666
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV120902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV260024338OtherRAILROAD MEDICARE
WV0116952000Medicaid
WV0116952000Medicaid
WVSU6014991Medicare PIN