Basic Information
| Provider Information | |||||||||
| NPI: | 1437103090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OSULLIVAN | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 159 BARNEGAT RD | ||||||||
| Address2: | NORTHERN MEDICAL GROUP, PLLC | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126015401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455924915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 CLOCK TOWER CMNS | ||||||||
| Address2: | NORTHERN MEDICAL GROUP, PLLC | ||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105094055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455924915 | ||||||||
| FaxNumber: | 8455924914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/11/2017 | ||||||||
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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 | 363A00000X | 009491 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02532709 | 05 | NY | MEDICAID |