Healthcare Provider Details

I. General information

NPI: 1215126065
Provider Name (Legal Business Name): GREGORY F. SULLIVAN , M.D., F.A.C.C., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 ROUTE 46 SUITE 202
CLIFTON NJ
07013-2449
US

IV. Provider business mailing address

1117 ROUTE 46 SUITE 202
CLIFTON NJ
07013-2449
US

V. Phone/Fax

Practice location:
  • Phone: 973-779-1221
  • Fax:
Mailing address:
  • Phone: 973-779-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA02285700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number25MA02285700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: DR. GREGORY FRANICS SULLIVAN II
Title or Position: MANAGER
Credential: PH.D., M.B.A.
Phone: 617-230-9317