Healthcare Provider Details

I. General information

NPI: 1851404768
Provider Name (Legal Business Name): MIRIAM JILL SULLIVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: M. JILL SULLIVAN

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST DEPARTMENT OF RADIOLOGY
SPRINGFIELD IL
62702-5324
US

IV. Provider business mailing address

319 E MADISON ST STE 2C
SPRINGFIELD IL
62701-3121
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-6464
  • Fax: 217-525-5671
Mailing address:
  • Phone: 217-544-2149
  • Fax: 217-525-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036063951
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: