Provider Demographics
NPI:1851404768
Name:SULLIVAN, MIRIAM JILL (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:JILL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:M. JILL
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:319 E MADISON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-3121
Mailing Address - Country:US
Mailing Address - Phone:217-544-2149
Mailing Address - Fax:217-525-5671
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5324
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-525-5671
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360639512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36063951Medicaid
ILP00028347OtherRR MEDICARE
IL300015701OtherRR MEDICARE
IL36063951Medicaid
ILL73423Medicare PIN
ILP00028347OtherRR MEDICARE