Basic Information
| Provider Information | |||||||||
| NPI: | 1437250412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 FRANKLIN ST SE | ||||||||
| Address2: | THE ORTHOPAEDIC CENTER | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565392728 | ||||||||
| FaxNumber: | 2564283423 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 FRANKLIN ST SE | ||||||||
| Address2: | THE ORTHOPAEDIC CENTER | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565392728 | ||||||||
| FaxNumber: | 2564283423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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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 | 363AS0400X | 1623 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7032826 | 01 | AL | AETNA | OTHER |