Healthcare Provider Details

I. General information

NPI: 1265750889
Provider Name (Legal Business Name): ROBERT G SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PENN PLAZA, 7TH FL. STE. 725 EVERCARE/UNITED HEALTHCARE
NEW YORK NY
10019
US

IV. Provider business mailing address

1 PENN PLAZA, 7TH FL. STE. 725 EVERCARE/UNITED HEALTHCARE
NEW YORK NY
10019
US

V. Phone/Fax

Practice location:
  • Phone: 212-216-6568
  • Fax: 212-216-6606
Mailing address:
  • Phone: 212-216-6568
  • Fax: 212-216-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number305274
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: