Provider Demographics
NPI:1154428803
Name:SULLIVAN, PAUL G (PT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1938 E LINCOLN HWY
Practice Address - Street 2:SUITE 111
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3810
Practice Address - Country:US
Practice Address - Phone:815-485-2916
Practice Address - Fax:815-485-2918
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCJ8115OtherR.R. MEDICARE GRP#
IL1619908OtherBCBS IL GROUP NUMBER
IL1623066OtherBCBS PROVIDER #
IL367885100OtherUS DEPT OF LABOR
ILCJ4383OtherR.R. MEDICARE GRP#
IL1623066OtherBCBS PROVIDER #
IL568150Medicare PIN
ILCJ8115OtherR.R. MEDICARE GRP#
ILK51892Medicare PIN
ILK51890Medicare PIN
IL567700Medicare PIN
ILK51892Medicare PIN
IL567700Medicare PIN