Provider Demographics
NPI:1174705628
Name:VINCENT E. SULLIVAN MD PC
Entity type:Organization
Organization Name:VINCENT E. SULLIVAN MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-437-1576
Mailing Address - Street 1:19878 SAINT JOSEPH DR
Mailing Address - Street 2:P.O. BOX 160
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-8850
Mailing Address - Country:US
Mailing Address - Phone:641-437-1576
Mailing Address - Fax:641-437-4205
Practice Address - Street 1:19878 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-8850
Practice Address - Country:US
Practice Address - Phone:641-437-1576
Practice Address - Fax:641-437-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18213208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0186270Medicaid
IA0186270Medicaid