Healthcare Provider Details

I. General information

NPI: 1417953647
Provider Name (Legal Business Name): PAUL EDWARD SULLIVAN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 ROUTE 73 N STE 401
MARLTON NJ
08053-1227
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 800-321-9999
  • Fax: 267-479-1321
Mailing address:
  • Phone: 800-321-9999
  • Fax: 267-339-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC003899L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number25MD00267000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: