Provider Demographics
NPI:1861453664
Name:SULLIVAN, PEGGY ANN (MD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:ANN
Other - Last Name:SULLIVAN MURTAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6936 PINE ARBOR DR S STE 100
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4661
Mailing Address - Country:US
Mailing Address - Phone:651-326-5800
Mailing Address - Fax:651-326-5802
Practice Address - Street 1:6936 PINE ARBOR DR S STE 100
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4661
Practice Address - Country:US
Practice Address - Phone:651-326-5800
Practice Address - Fax:651-326-5802
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN587017800Medicaid
080004482Medicare ID - Type Unspecified
MN587017800Medicaid