MEDICARE: JULIE GAIL SULLIVAN M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	23824	OK

General Provider Information

NPI Number	:	1578568010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE GAIL SULLIVAN M.D.

Provider Business Mailing Address
First Line	:	1615 S EUCALYPTUS AVE
Second Line	:	SUITE 210
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-6159
Country	:	US
Telephone Number	:	918-254-6822
Fax Number	:	918-254-6823

Provider Business Practice Location Address
First Line	:	1615 S EUCALYPTUS AVE
Second Line	:	SUITE 210
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-6159
Country	:	US
Telephone Number	:	918-254-6822
Fax Number	:	918-254-6823

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	01/24/2017

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