MEDICARE: DR. ETHAN M SULLIVAN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	019782	OH

General Provider Information

NPI Number	:	1548980659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHAN M SULLIVAN DPT

Provider Business Mailing Address
First Line	:	2306 FAR HILLS AVE
Second Line	:
City	:	OAKWOOD
State	:	OH
Zip	:	45419-1512
Country	:	US
Telephone Number	:	937-422-2600
Fax Number	:

Provider Business Practice Location Address
First Line	:	2306 FAR HILLS AVE
Second Line	:
City	:	OAKWOOD
State	:	OH
Zip	:	45419-1512
Country	:	US
Telephone Number	:	937-422-2600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2022
Last Update Date	:	08/30/2022

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