Basic Information
| Provider Information | |||||||||
| NPI: | 1770506271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17850 KEDZIE AVE STE 3250 | ||||||||
| Address2: | |||||||||
| City: | HAZEL CREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604292082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087798700 | ||||||||
| FaxNumber: | 7089571830 | ||||||||
| Practice Location | |||||||||
| Address1: | 17850 KEDZIE AVE STE 3250 | ||||||||
| Address2: | |||||||||
| City: | HAZEL CREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604292082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087798700 | ||||||||
| FaxNumber: | 7089571830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036093913 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036093913 | 05 | IL | MEDICAID |