Provider Demographics
NPI:1053341370
Name:SULLIVAN, JON M (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5371
Mailing Address - Fax:740-446-5711
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5371
Practice Address - Fax:740-446-5711
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16987208000000X
OH35-05-4754208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000181879OtherUNISON MEDICAID #
001714064OtherMOUNTAIN STATE BCBS
OH0882719OtherMOLINA MEDICAID #
WV000000006810OtherANTHEM BCBS
OH370002760OtherRR MEDICARE
000000007592OtherANTHEM BCBS
WV0107833000Medicaid
OH0882719Medicaid
OH310917085065OtherCARESOURCE MEDICAID #
000000007592OtherANTHEM BCBS
OH0882719OtherMOLINA MEDICAID #
OH370002760OtherRR MEDICARE