=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215909528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAURA ELLEN SULLIVAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 PARKMAN ST PEDIATRIC MEDICINE WAC 715
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-724-2174
-----------------------------------------------------
Fax | 617-726-4267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
-----------------------------------------------------
City | CHARLESTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02129-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-724-0287
-----------------------------------------------------
Fax | 617-726-2894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 150898
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------