Provider Demographics
NPI:1962493692
Name:SULLIVAN, MARION LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARION
Middle Name:LOUISE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9842 N 52ND ST
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1018
Mailing Address - Country:US
Mailing Address - Phone:480-348-1678
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:602-299-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17124207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0728670OtherBCBS GROUP
AZ4153051001OtherGROUP HEALTH GROUP NUMBER
AZ39-87220OtherEVERCARE GROUP
AZ411009Medicaid
AZAW1936OtherHEALTHNET GROUP
AZAZ0728670OtherBCBS GROUP
AZ39-87220OtherEVERCARE GROUP