Provider Demographics
NPI:1831157999
Name:SULLIVAN, HENRY JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9500 BORMET DR STE 204
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8399
Mailing Address - Country:US
Mailing Address - Phone:708-346-4044
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:4400 W 95TH ST STE 308
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2660
Practice Address - Country:US
Practice Address - Phone:708-346-4040
Practice Address - Fax:708-346-3287
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036041828208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041828Medicaid
IL969780017Medicare PIN
IL036041828Medicaid