Basic Information
| Provider Information | |||||||||
| NPI: | 1013985134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 E REPUBLIC RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658046530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178896102 | ||||||||
| FaxNumber: | 4178896289 | ||||||||
| Practice Location | |||||||||
| Address1: | 7330 RYEGRASS ROAD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077339105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 09/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | R6F03 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1256 | 01 | MO | BLUE | OTHER | 202340501 | 05 | MO | MEDICAID | 110826001 | 05 | AR | MEDICAID | 300034332 | 01 | MO | RRR MEDICARE | OTHER |