Healthcare Provider Details

I. General information

NPI: 1609967314
Provider Name (Legal Business Name): JANET SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 FORUM BLVD STE 103
COLUMBIA MO
65203-6364
US

IV. Provider business mailing address

2412 FORUM BLVD STE 103
COLUMBIA MO
65203-6364
US

V. Phone/Fax

Practice location:
  • Phone: 573-445-0725
  • Fax: 573-445-1027
Mailing address:
  • Phone: 573-445-0725
  • Fax: 573-445-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009003022
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: