1750551834 NPI number — KEVIN L. SULLIVAN MD, PC

Table of content: (NPI 1750551834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750551834 NPI number — KEVIN L. SULLIVAN MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN L. SULLIVAN MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750551834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 VALLEY STREAM PKWY
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
MALVERN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19355-1407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-644-8900
Provider Business Mailing Address Fax Number:
484-924-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 E PONCE DE LEON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-3440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-377-9171
Provider Business Practice Location Address Fax Number:
404-977-9172
Provider Enumeration Date:
03/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
404-377-9171

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)