Healthcare Provider Details

I. General information

NPI: 1225041536
Provider Name (Legal Business Name): JONATHON C. SULLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 STAFFORD AVENUE
SCRANTON PA
18505-0305
US

IV. Provider business mailing address

2601 STAFFORD AVENUE PO BOX 3305
SCRANTON PA
18505-0305
US

V. Phone/Fax

Practice location:
  • Phone: 570-346-6633
  • Fax:
Mailing address:
  • Phone: 570-346-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD020198E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000083999
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerTHREE RIVERS
# 2
Identifier300020246
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier0004210397
Identifier TypeOTHER
Identifier StatePA
Identifier Issuer0004210397
# 4
Identifier0006585310012
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 5
IdentifierC31604
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE CROSS
# 6
Identifier141629
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 7
Identifier20007413
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAMERIHEALTH MERCY
# 8
Identifier10624 1686
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: