Provider Demographics
NPI:1003804352
Name:SULLIVAN, MANLY JACKSON (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:MANLY
Middle Name:JACKSON
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 ROBERT K WILSON DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:AL
Mailing Address - Zip Code:35447-8010
Mailing Address - Country:US
Mailing Address - Phone:205-367-2408
Mailing Address - Fax:205-367-9123
Practice Address - Street 1:241 ROBERT K WILSON DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:AL
Practice Address - Zip Code:35447-8010
Practice Address - Country:US
Practice Address - Phone:205-367-2408
Practice Address - Fax:205-367-9123
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20081207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG42261Medicare UPIN
AL33998Medicare ID - Type UnspecifiedPROVIDER NUMBER