Healthcare Provider Details

I. General information

NPI: 1780987750
Provider Name (Legal Business Name): SULLIVAN PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 FORUM BLVD
COLUMBIA MO
65203-5431
US

IV. Provider business mailing address

2614 FORUM BLVD
COLUMBIA MO
65203-5431
US

V. Phone/Fax

Practice location:
  • Phone: 573-999-1657
  • Fax: 650-560-1839
Mailing address:
  • Phone: 573-999-1657
  • Fax: 650-560-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JANET SULLIVAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 573-999-1657