Provider Demographics
NPI:1669468278
Name:SULLIVAN PLASTIC AND RECONSTRUCTIVE SURGEY CENTER, INC
Entity Type:Organization
Organization Name:SULLIVAN PLASTIC AND RECONSTRUCTIVE SURGEY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-436-8888
Mailing Address - Street 1:7706 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1317
Mailing Address - Country:US
Mailing Address - Phone:614-436-8888
Mailing Address - Fax:614-436-8847
Practice Address - Street 1:7706 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1317
Practice Address - Country:US
Practice Address - Phone:614-436-8888
Practice Address - Fax:614-436-8847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH216 / ID 0317AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical