Provider Demographics
NPI:1023168796
Name:SULLIVAN, RICHARD PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PATRICK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 RIDGE RD W
Mailing Address - Street 2:BUILDING C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3249
Mailing Address - Country:US
Mailing Address - Phone:585-225-1700
Mailing Address - Fax:585-225-1439
Practice Address - Street 1:3101 RIDGE RD W
Practice Address - Street 2:BUILDING C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3249
Practice Address - Country:US
Practice Address - Phone:585-225-1700
Practice Address - Fax:585-225-1439
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142774208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00740996Medicaid
NYC58360Medicare UPIN
NY12115CMedicare ID - Type Unspecified