Healthcare Provider Details

I. General information

NPI: 1437358835
Provider Name (Legal Business Name): SHAWN E SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 E BASELINE RD STE 108
MESA AZ
85206
US

IV. Provider business mailing address

645 E MISSOURI AVE STE 300
PHOENIX AZ
85012-1351
US

V. Phone/Fax

Practice location:
  • Phone: 480-981-2400
  • Fax: 480-981-2407
Mailing address:
  • Phone: 602-262-8900
  • Fax: 602-262-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number37097
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number37097
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: