Provider Demographics
NPI:1891983417
Name:MICHELLE L SULLIVAN DO PC
Entity Type:Organization
Organization Name:MICHELLE L SULLIVAN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:877-905-0336
Mailing Address - Street 1:1300 COPPERFIELD AVE
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-2004
Mailing Address - Country:US
Mailing Address - Phone:877-905-0336
Mailing Address - Fax:877-905-0336
Practice Address - Street 1:1300 COPPERFIELD AVE
Practice Address - Street 2:SUITE 1020
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-2004
Practice Address - Country:US
Practice Address - Phone:877-905-0336
Practice Address - Fax:877-905-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty