Healthcare Provider Details

I. General information

NPI: 1750361036
Provider Name (Legal Business Name): VINCENT E. SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19878 SAINT JOSEPH DR
CENTERVILLE IA
52544-8850
US

IV. Provider business mailing address

19878 SAINT JOSEPH DR POST OFFICE BOX 160
CENTERVILLE IA
52544-8850
US

V. Phone/Fax

Practice location:
  • Phone: 641-437-1576
  • Fax: 641-437-4205
Mailing address:
  • Phone: 641-437-1576
  • Fax: 641-437-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number18213
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0186270
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: