Provider Demographics
NPI:1538316310
Name:BRENDAN P SULLIVAN MD FACC LLC
Entity Type:Organization
Organization Name:BRENDAN P SULLIVAN MD FACC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-779-5151
Mailing Address - Street 1:183 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4105
Mailing Address - Country:US
Mailing Address - Phone:201-612-7893
Mailing Address - Fax:201-857-8460
Practice Address - Street 1:265 ACKERMAN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4200
Practice Address - Country:US
Practice Address - Phone:201-445-8820
Practice Address - Fax:201-445-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA072777207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI03869Medicare UPIN