Individual
JOHN A. SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
7330 RYEGRASS ROAD, JACKSON, WY 83001
(307) 733-9105
Mailing address
1550 E REPUBLIC RD, SPRINGFIELD, MO 65804-6530
(417) 889-6102
(417) 889-6289
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
R6F03
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110826001
—
AR
01
—
1256
BLUE
MO
05
—
202340501
—
MO
01
—
300034332
RRR MEDICARE
MO
Enumeration date
03/14/2006
Last updated
09/10/2009
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