Provider Demographics
NPI:1477653897
Name:DENNIS P. SULLIVAN, M.D., INC.
Entity Type:Organization
Organization Name:DENNIS P. SULLIVAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-399-8921
Mailing Address - Street 1:30 W. MCCREIGHT AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504
Mailing Address - Country:US
Mailing Address - Phone:937-399-8921
Mailing Address - Fax:937-629-9248
Practice Address - Street 1:30 W. MCCREIGHT AVE STE 103
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504
Practice Address - Country:US
Practice Address - Phone:937-399-8921
Practice Address - Fax:937-629-9248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-037690174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2945273Medicaid
OHSU4262411OtherMEDICARE PTAN
OH2945273Medicaid
OHCO1686Medicare UPIN