Provider Demographics
NPI:1427189638
Name:JAY F SULLIVAN MD PC
Entity Type:Organization
Organization Name:JAY F SULLIVAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-298-2768
Mailing Address - Street 1:4882B NORTH JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4882B NORTH JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142
Practice Address - Country:US
Practice Address - Phone:315-298-2768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY691259OtherMVP
NY138562OtherCIGNA
NY799222OtherAETNA HMO
NY01538238Medicaid
NY5939163OtherAETNA
NY169461-1WOtherWORKERS COMPENSATION
NY00020708301OtherUNIVERA
NY691259OtherMVP
NY799222OtherAETNA HMO