Healthcare Provider Details

I. General information

NPI: 1275607624
Provider Name (Legal Business Name): RICHARD JOSEPH SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7904 TURIN RD
ROME NY
13440-1933
US

IV. Provider business mailing address

PO BOX 4440
ROME NY
13442-4440
US

V. Phone/Fax

Practice location:
  • Phone: 315-336-3400
  • Fax: 315-336-2691
Mailing address:
  • Phone: 315-336-3400
  • Fax: 315-336-2691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number116001
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: