=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780987750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SULLIVAN PEDIATRICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2010
-----------------------------------------------------
Last Update Date | 12/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2614 FORUM BLVD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-5431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-999-1657
-----------------------------------------------------
Fax | 650-560-1839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2614 FORUM BLVD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-5431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-999-1657
-----------------------------------------------------
Fax | 650-560-1839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JANET SULLIVAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 573-999-1657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2009003022
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------