Healthcare Provider Details

I. General information

NPI: 1184529372
Provider Name (Legal Business Name): BRYANNA MCGOWAN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRYANNA MCGOWAN MD

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

1450 W CHESTNUT ST APT 1
CHICAGO IL
60642-5559
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-3229
  • Fax:
Mailing address:
  • Phone: 845-282-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: