Provider Demographics
NPI:1588672927
Name:SULLIVAN, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1001 S MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4748
Mailing Address - Country:US
Mailing Address - Phone:717-697-5050
Mailing Address - Fax:717-591-0920
Practice Address - Street 1:1001 S MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-4748
Practice Address - Country:US
Practice Address - Phone:717-697-5050
Practice Address - Fax:717-591-0920
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD018511-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAD71153Medicare UPIN
PASU98201Medicare ID - Type Unspecified