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Individual
JERRY SULLIVAN
Active
Individual
JERRY SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
070-002636
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070002636
STATE LICENSE
IL
01
—
753210
MEDICARE GROUP
—
01
—
CF2064
RAILROAD GROUP
—
Enumeration date
12/29/2005
Last updated
10/25/2013
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