Provider Demographics
NPI:1790949980
Name:LISA SULLIVAN, MD S.C.
Entity Type:Organization
Organization Name:LISA SULLIVAN, MD S.C.
Other - Org Name:PANACEA ALLERGY, ASTHMA & IMMUNOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-805-8088
Mailing Address - Street 1:19818 CYPRESS BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4399
Mailing Address - Country:US
Mailing Address - Phone:847-805-8088
Mailing Address - Fax:847-805-8844
Practice Address - Street 1:737 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4650
Practice Address - Country:US
Practice Address - Phone:847-805-8088
Practice Address - Fax:847-805-8088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207K00000X
IL036107599261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
217064Medicare PIN