Provider Demographics
NPI:1689600686
Name:SULLIVAN, JOHN S (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE # 4903
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-1231
Practice Address - Country:US
Practice Address - Phone:570-214-8790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1674252080P0203X
PAMD041640E2080P0203X
NC95004572080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463854Medicaid
NY01463854Medicaid
G81732Medicare UPIN