Healthcare Provider Details

I. General information

NPI: 1952368557
Provider Name (Legal Business Name): JOHN PATRICK SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W BARAGA AVE
MARQUETTE MI
49855-4550
US

IV. Provider business mailing address

1218 S BROADWAY SUITE 310
LEXINGTON KY
40504-2759
US

V. Phone/Fax

Practice location:
  • Phone: 906-449-3000
  • Fax:
Mailing address:
  • Phone: 859-219-0542
  • Fax: 859-219-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number39464
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: