Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 258579 | MA |
N | 207VF0040X | Female Pelvic Medicine and Reconstructive Surgeon | 258579 | MA |
NPI | 1265750228 |
---|---|
Provider Name | Gina T Sullivan |
First Address | Boston, MA 02241-5348 |
Second Address | Worcester, MA 01605-2726 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2010 |
Last Update Date | 10/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110104869A | (05) | MA |