Provider Demographics
NPI:1679564124
Name:GENERAL AND VASCULAR SURGERY OF ENNIS PA
Entity type:Organization
Organization Name:GENERAL AND VASCULAR SURGERY OF ENNIS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-878-4700
Mailing Address - Street 1:802 W LAMPASAS ST
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-4500
Mailing Address - Country:US
Mailing Address - Phone:972-878-4700
Mailing Address - Fax:972-878-2238
Practice Address - Street 1:802 W LAMPASAS ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4500
Practice Address - Country:US
Practice Address - Phone:972-878-4700
Practice Address - Fax:972-878-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00266VOtherMEDICARE PTAN
TX159614002Medicaid
TX00266VOtherMEDICARE PTAN