Healthcare Provider Details

I. General information

NPI: 1932184843
Provider Name (Legal Business Name): MILLER J SULLIVAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6096 E MAIN ST STE 112
COLUMBUS OH
43213-4302
US

IV. Provider business mailing address

6096 E MAIN ST STE 112
COLUMBUS OH
43213-4302
US

V. Phone/Fax

Practice location:
  • Phone: 614-755-3000
  • Fax: 614-755-4052
Mailing address:
  • Phone: 614-755-3000
  • Fax: 614-755-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-05-7174
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: