Basic Information
| Provider Information | |||||||||
| NPI: | 1740200377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 N MAIN ST | ||||||||
| Address2: | SUITE 245 | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602363000 | ||||||||
| FaxNumber: | 8602363002 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 N MAIN ST | ||||||||
| Address2: | SUITE 245 | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602363000 | ||||||||
| FaxNumber: | 8602363002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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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 | 207Q00000X | 000527 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001005273 | 05 | CT | MEDICAID |