Basic Information
| Provider Information | |||||||||
| NPI: | 1306998406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6501 LOISDALE CT | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221501826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039221000 | ||||||||
| FaxNumber: | 7039221039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00017070 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101243402 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D0071387 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD039385 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8103087 | 05 | WA | MEDICAID |