Provider Demographics
NPI:1104074806
Name:MARY LYNN SULLIVAN, M.D.P.C.
Entity type:Organization
Organization Name:MARY LYNN SULLIVAN, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-499-4190
Mailing Address - Street 1:5660 W 95TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2380
Mailing Address - Country:US
Mailing Address - Phone:708-499-4190
Mailing Address - Fax:708-857-4427
Practice Address - Street 1:5660 W 95TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2380
Practice Address - Country:US
Practice Address - Phone:708-499-4190
Practice Address - Fax:708-857-4427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077688261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE18982Medicare UPIN