Basic Information
| Provider Information | |||||||||
| NPI: | 1588671895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MURRAY | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 W WALLACE ST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458401239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194235262 | ||||||||
| FaxNumber: | 4194235550 | ||||||||
| Practice Location | |||||||||
| Address1: | 139 GARAU ST | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458171027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193589010 | ||||||||
| FaxNumber: | 4193581189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 35064725 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2342594 | 05 | OH | MEDICAID |