Provider Demographics
NPI:1386686434
Name:SULLIVAN, PHYLLIS L (DO)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2330 SHAWNEE MISSION PKWY
Mailing Address - Street 2:MEDICAL ADMINISTRATIVE SERVICES OF KU MED, STE. 312
Mailing Address - City:WESTWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2005
Mailing Address - Country:US
Mailing Address - Phone:913-588-9000
Mailing Address - Fax:913-588-9822
Practice Address - Street 1:7405 RENNER RD
Practice Address - Street 2:KU MEDWEST
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66217-9414
Practice Address - Country:US
Practice Address - Phone:913-588-8400
Practice Address - Fax:913-588-8413
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS05-24472207Q00000X
MOR1H49207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
481159444OtherJAYHAWK TAX ID
KS100231070BMedicaid
10001636401OtherCHP PROVIDER NUMBER
326972OtherFIRSTGUARD
P00052983OtherRR MEDICARE
13470888OtherBCBS
157695XXOtherPREFERRED CARE OF NY
25562039OtherBCBS KUMW UC
4331498OtherAETNA
481159444OtherJAYHAWK TAX ID
13470888OtherBCBS