Provider Demographics
NPI:1548513799
Name:TIMOTHY SULLIVAN, MD PC
Entity type:Organization
Organization Name:TIMOTHY SULLIVAN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:801-387-4850
Mailing Address - Street 1:4403 HARRISON BLVD
Mailing Address - Street 2:STE# 4640
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-4850
Mailing Address - Fax:801-387-4855
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE# 4640
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-4850
Practice Address - Fax:801-387-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8263858-1205207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty