Healthcare Provider Details

I. General information

NPI: 1386650273
Provider Name (Legal Business Name): LISA MARIE SULLIVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA SULLIVAN MD

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 SAINT JOHNS AVE
HIGHLAND PARK IL
60035-4650
US

IV. Provider business mailing address

19818 CYPRESS BRIDGE DR
ODESSA FL
33556-4399
US

V. Phone/Fax

Practice location:
  • Phone: 847-805-8088
  • Fax: 847-805-8844
Mailing address:
  • Phone: 847-805-8088
  • Fax: 847-805-8844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number36107599
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number36107599
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number36107599
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number36107599
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: