Provider Demographics
NPI:1225041536
Name:SULLUM, JONATHON C (MD)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:C
Last Name:SULLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 STAFFORD AVENUE
Mailing Address - Street 2:PO BOX 3305
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-0305
Mailing Address - Country:US
Mailing Address - Phone:570-346-6633
Mailing Address - Fax:
Practice Address - Street 1:2601 STAFFORD AVENUE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-0305
Practice Address - Country:US
Practice Address - Phone:570-346-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020198E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000000083999OtherTHREE RIVERS
PA300020246OtherRAILROAD MEDICARE
PA0004210397Other0004210397
PA0006585310012Medicaid
PAC31604OtherBLUE CROSS
PA141629OtherHIGHMARK BLUE SHIELD
PA20007413OtherAMERIHEALTH MERCY
PA10624 1686OtherGEISINGER HEALTH PLAN
PA20007413OtherAMERIHEALTH MERCY
PA000000083999OtherTHREE RIVERS