Provider Demographics
NPI:1437650231
Name:SULLIVAN, EDWARD T
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ALLIED DR STE 303
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-6148
Mailing Address - Country:US
Mailing Address - Phone:781-267-2305
Mailing Address - Fax:
Practice Address - Street 1:3 ALLIED DRIVE STE 303
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-0202
Practice Address - Country:US
Practice Address - Phone:781-267-2305
Practice Address - Fax:888-316-2179
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MA16059502330374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty