Provider Demographics
NPI:1215126065
Name:GREGORY F. SULLIVAN , M.D., F.A.C.C., P.A.
Entity type:Organization
Organization Name:GREGORY F. SULLIVAN , M.D., F.A.C.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:FRANICS
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD, MBA
Authorized Official - Phone:617-230-9317
Mailing Address - Street 1:1117 ROUTE 46
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2449
Mailing Address - Country:US
Mailing Address - Phone:973-779-1221
Mailing Address - Fax:
Practice Address - Street 1:1117 ROUTE 46
Practice Address - Street 2:SUITE 202
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2449
Practice Address - Country:US
Practice Address - Phone:973-779-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02285700207RC0000X, 207RI0011X
NJ207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ076770Medicare PIN