MEDICARE: DR. DANIEL JOSEPH 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	207XS0117X	Orthopaedic Surgery of the Spine Physician	35063476S	OH
2	207XS0117X	Orthopaedic Surgery of the Spine Physician	38140	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801895834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL JOSEPH SULLIVAN M.D.

Provider Business Mailing Address
First Line	:	1739 BEVERLY AVE
Second Line	:	SUITE 107
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3593
Country	:	US
Telephone Number	:	928-681-8565
Fax Number	:	928-681-8564

Provider Business Practice Location Address
First Line	:	1739 BEVERLY AVE
Second Line	:	SUITE 107
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3593
Country	:	US
Telephone Number	:	928-681-8565
Fax Number	:	928-681-8564

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	10/06/2008

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