Basic Information
| Provider Information | |||||||||
| NPI: | 1255370326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 ASYLUM AVE | ||||||||
| Address2: | SUITE 2120 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602464000 | ||||||||
| FaxNumber: | 8605276985 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 ASYLUM AVE | ||||||||
| Address2: | SUITE 2120 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602464000 | ||||||||
| FaxNumber: | 8605276985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 07/07/2010 | ||||||||
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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 | 174400000X | 021621 | CT | N | Other Service Providers | Specialist | 208600000X | 021621 | CT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001216217 | 05 | CT | MEDICAID |