Individual
JAY FREDERICK SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4882B NORTH JEFFERSON STREET, PULASKI, NY 13142
(315) 298-2768
(315) 298-2846
Mailing address
4882B NORTH JEFFERSON STREET, PULASKI, NY 13142
(315) 298-2768
(315) 298-2846
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
169461
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000006298
RMSCO
—
01
—
00020708301
UNIVERA
—
05
—
01538238
—
NY
01
—
080155488
MEDICARE RAILROAD
—
01
—
138562
CIGNA
—
01
—
161577435
POMCO
—
01
—
169461-1W
WORKER'S COMPENSATION
—
01
—
5900753
GHI
—
01
—
5939163
AETNA NON HMO
—
01
—
691259
MVP
—
01
—
799222
AETNA HMO
—
01
—
CC6514
MEDICARE
—
Enumeration date
07/10/2006
Last updated
01/07/2021
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