Provider Demographics
NPI:1497024178
Name:RICHARD J SULLIVAN, M.D., P.C.
Entity Type:Organization
Organization Name:RICHARD J SULLIVAN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-336-3400
Mailing Address - Street 1:7904 TURIN RD
Mailing Address - Street 2:PO BOX 4440
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-1933
Mailing Address - Country:US
Mailing Address - Phone:315-336-3400
Mailing Address - Fax:
Practice Address - Street 1:7904 TURIN RD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-1933
Practice Address - Country:US
Practice Address - Phone:315-336-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116001-1261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30193BMedicare UPIN