Healthcare Provider Details

I. General information

NPI: 1376562694
Provider Name (Legal Business Name): RYAN J SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 UNIVERSITY BLVD E
TUSCALOOSA AL
35401-2071
US

IV. Provider business mailing address

2259 W SAINT PAUL AVE
CHICAGO IL
60647-5425
US

V. Phone/Fax

Practice location:
  • Phone: 205-759-6925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036-113954
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036-113954
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number558-320
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number37362
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: