Provider Demographics
NPI:1497722615
Name:SULLIVAN, MARK F SR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:SULLIVAN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 E ANTIETAM ST
Mailing Address - Street 2:STE 106
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5736
Mailing Address - Country:US
Mailing Address - Phone:301-739-6147
Mailing Address - Fax:301-739-6163
Practice Address - Street 1:11236 ROBINWOOD DR
Practice Address - Street 2:# 7
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6708
Practice Address - Country:US
Practice Address - Phone:301-665-4760
Practice Address - Fax:301-665-4761
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038772E208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11528138OtherAETNA
PA348403OtherHIGHMARK
PA0017873640003Medicaid
F85867Medicare UPIN
PA11528138OtherAETNA