Provider Demographics
NPI:1962781948
Name:SHAWN M SULLIVAN DO PC
Entity type:Organization
Organization Name:SHAWN M SULLIVAN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-949-0298
Mailing Address - Street 1:3295 N DRINKWATER BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6437
Mailing Address - Country:US
Mailing Address - Phone:480-949-0298
Mailing Address - Fax:480-949-1258
Practice Address - Street 1:3295 N DRINKWATER BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6437
Practice Address - Country:US
Practice Address - Phone:480-949-0298
Practice Address - Fax:480-949-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ459009Medicaid
AZ459009Medicaid