Basic Information
| Provider Information | |||||||||
| NPI: | 1831106863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259258 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3550 MARKET ST FL 3 | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA - ALLERGY & IMMUN | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902549 | ||||||||
| FaxNumber: | 2155904529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD050758L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080I0007X | MD050758L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Clinical & Laboratory Immunology | 2080P0216X | MD050758L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology | 2080P0201X | MD050758L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
| ID | Type | State | Issuer | Description | 001431101 | 05 | PA | MEDICAID | 5617308 | 05 | NJ | MEDICAID |