Jon M. Sullivan, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

35-05-4754 Issued in OH

Practice address

100 Jackson Pike
Gallipolis, OH 45631-1560

Phone

(740) 446-5371

Fax

(740) 446-5711

NPI assigned

Jul 3, 2006

Last updated

Dec 29, 2020By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 9

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151884800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1609200000000",
    "number": "1053341370",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "90 JACKSON PIKE",
            "city": "GALLIPOLIS",
            "state": "OH",
            "postal_code": "456311560",
            "telephone_number": "740-446-5371",
            "fax_number": "740-446-5711"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 JACKSON PIKE",
            "city": "GALLIPOLIS",
            "state": "OH",
            "postal_code": "456311560",
            "telephone_number": "740-446-5371",
            "fax_number": "740-446-5711"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SULLIVAN",
        "first_name": "JON",
        "middle_name": "M.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-03",
        "last_updated": "2020-12-29",
        "certification_date": "2020-12-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "WV",
            "license": "16987",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "OH",
            "license": "35-05-4754",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNISON MEDICAID #",
            "identifier": "000000181879",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MOUNTAIN STATE BCBS",
            "identifier": "001714064",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "370002760",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MOLINA MEDICAID #",
            "identifier": "0882719",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CARESOURCE MEDICAID #",
            "identifier": "310917085065",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BCBS",
            "identifier": "000000006810",
            "state": "WV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0107833000",
            "state": "WV"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BCBS",
            "identifier": "000000007592",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0882719",
            "state": "OH"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jon.sullivan.1@17389.direct.athenahealth.com",
            "affiliation": "N",
            "address_1": "100 Jackson Pike",
            "city": "Gallipolis",
            "state": "OH",
            "country_code": "US",
            "postal_code": "456311560",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Rebecca Ann Stump, OD
• Rebecca J Stump, CNP
• Meloney Sturgill, CDCA
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• Anthony Wayne Syrus
• Tasc of Southeast Ohio
• Tasc of Southeast Ohio
• Ronald Tawney, CNP

• Pediatrics Physician in Gallipolis, OH
• Providers in Gallipolis, OH by specialty
• Pediatrics Physician in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 29, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.