Basic Information
| Provider Information | |||||||||
| NPI: | 1558397182 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1203 PINEHURST DR | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334265879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614002729 | ||||||||
| FaxNumber: | 5613745717 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 S SEACREST BLVD | ||||||||
| Address2: | BETHESDA MEMORIAL HOSPITAL | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334357934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617377733 | ||||||||
| FaxNumber: | 5613745717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | OS6041 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 44456 | 01 | FL | BCBS FL | OTHER | 255004100 | 05 | FL | MEDICAID |