Provider Demographics
NPI:1700934361
Name:SULLIVAN, EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CAYUGA RD
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1155
Mailing Address - Country:US
Mailing Address - Phone:585-396-2150
Mailing Address - Fax:585-396-2150
Practice Address - Street 1:40 CAYUGA RD
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1155
Practice Address - Country:US
Practice Address - Phone:585-396-2150
Practice Address - Fax:585-396-2150
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY07349111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30710Medicare UPIN
NY11008BMedicare ID - Type Unspecified