Basic Information
Provider Information | |||||||||
NPI: | 1548513799 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TIMOTHY SULLIVAN, MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4403 HARRISON BLVD | ||||||||
Address2: | STE# 4640 | ||||||||
City: | OGDEN | ||||||||
State: | UT | ||||||||
PostalCode: | 844033271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013874850 | ||||||||
FaxNumber: | 8013874855 | ||||||||
Practice Location | |||||||||
Address1: | 4403 HARRISON BLVD | ||||||||
Address2: | STE# 4640 | ||||||||
City: | OGDEN | ||||||||
State: | UT | ||||||||
PostalCode: | 844033271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013874850 | ||||||||
FaxNumber: | 8013874855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2012 | ||||||||
LastUpdateDate: | 10/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SULLIVAN | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
AuthorizedOfficialTelephone: | 8013874850 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 8263858-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
No ID Information.