Healthcare Provider Details

I. General information

NPI: 1215106067
Provider Name (Legal Business Name): STEVEN W SULLIVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 IDLEWILD AVE STE 105
EASTON MD
21601-4049
US

IV. Provider business mailing address

1600 S. CRAIN HIGHWAY SUITE 401
GLEN BURNIE MD
21060
US

V. Phone/Fax

Practice location:
  • Phone: 855-527-7246
  • Fax: 866-229-5063
Mailing address:
  • Phone: 410-768-5050
  • Fax: 410-768-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003015
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: