Basic Information
| Provider Information | |||||||||
| NPI: | 1053341370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465371 | ||||||||
| FaxNumber: | 7404465711 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465371 | ||||||||
| FaxNumber: | 7404465711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 16987 | WV | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35-05-4754 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000181879 | 01 | OH | UNISON MEDICAID # | OTHER | 001714064 | 01 | MOUNTAIN STATE BCBS | OTHER | 0882719 | 01 | OH | MOLINA MEDICAID # | OTHER | 000000006810 | 01 | WV | ANTHEM BCBS | OTHER | 370002760 | 01 | OH | RR MEDICARE | OTHER | 000000007592 | 01 | ANTHEM BCBS | OTHER | 0107833000 | 05 | WV | MEDICAID | 0882719 | 05 | OH | MEDICAID | 310917085065 | 01 | OH | CARESOURCE MEDICAID # | OTHER |