Healthcare Provider Details

I. General information

NPI: 1780643908
Provider Name (Legal Business Name): BRENDAN L SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9010 LORTON STATION BLVD SUITE 100
LORTON VA
22079-4792
US

IV. Provider business mailing address

1500 N BEAUREGARD ST SUITE 200
ALEXANDRIA VA
22311-1723
US

V. Phone/Fax

Practice location:
  • Phone: 703-436-1200
  • Fax: 703-642-0392
Mailing address:
  • Phone: 703-436-1200
  • Fax: 703-575-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101227543
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: