Healthcare Provider Details

I. General information

NPI: 1851431670
Provider Name (Legal Business Name): LEO W SULLIVAN. II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

IV. Provider business mailing address

902 MONTEREY DR
O FALLON IL
62269-2833
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-5879
  • Fax: 618-257-6740
Mailing address:
  • Phone: 618-624-8701
  • Fax: 618-624-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036068595
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: