Basic Information
| Provider Information | |||||||||
| NPI: | 1417953647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 520 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003219999 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 999 ROUTE 73 N STE 401 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080531227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003219999 | ||||||||
| FaxNumber: | 2674791321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC003899L | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | 25MD00267000 | NJ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8925704 | 05 | NJ | MEDICAID |