Basic Information
| Provider Information | |||||||||
| NPI: | 1225070022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2200 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030314200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036739411 | ||||||||
| FaxNumber: | 6036739899 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 MIDDLESEX AVE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018872737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786584432 | ||||||||
| FaxNumber: | 9786585751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33493 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 706387 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 164920 | 01 | CIGNA HEALTHSOURCE | OTHER | 2061899 | 05 | MA | MEDICAID | 70503 | 01 | HARVARD PILGRIM | OTHER | B52010 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 0015705 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 35943 | 01 | MA | FALLON COMMUNITY HEALTH | OTHER | B10030001 | 01 | CIGNA | OTHER |