Provider Demographics
NPI:1952368557
Name:SULLIVAN, JOHN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
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 1:1218 S BROADWAY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2759
Mailing Address - Country:US
Mailing Address - Phone:859-219-0542
Mailing Address - Fax:859-219-9433
Practice Address - Street 1:850 W BARAGA AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4550
Practice Address - Country:US
Practice Address - Phone:906-449-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY394642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64098940Medicaid
0581218Medicare ID - Type Unspecified
0723616Medicare ID - Type Unspecified
0572118Medicare PIN
0674616Medicare ID - Type Unspecified
0682007Medicare ID - Type Unspecified
0946412Medicare ID - Type Unspecified
KY64098940Medicaid
0765716Medicare ID - Type Unspecified
0572018Medicare ID - Type Unspecified
0571818Medicare ID - Type Unspecified
0991710Medicare ID - Type Unspecified
0950212Medicare ID - Type Unspecified