Provider Demographics
NPI:1942063136
Name:EDWARD MARK SULLIVAN
Entity type:Organization
Organization Name:EDWARD MARK SULLIVAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-696-8400
Mailing Address - Street 1:570 N STATE ST STE 220C
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8086
Mailing Address - Country:US
Mailing Address - Phone:614-696-8400
Mailing Address - Fax:614-362-9909
Practice Address - Street 1:570 N STATE ST STE 220C
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8086
Practice Address - Country:US
Practice Address - Phone:614-696-8400
Practice Address - Fax:614-362-9909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0041581Medicaid