Healthcare Provider Details

I. General information

NPI: 1619971280
Provider Name (Legal Business Name): BRONYA BOYKIN SULLIVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W BROAD ST
COLUMBUS OH
43223-1297
US

IV. Provider business mailing address

2200 W BROAD ST
COLUMBUS OH
43223-1297
US

V. Phone/Fax

Practice location:
  • Phone: 614-752-0333
  • Fax:
Mailing address:
  • Phone: 614-752-0333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number054553
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.095997
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.123716
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: