Provider Demographics
NPI:1043385651
Name:SULLIVAN, MICHAEL TERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TERRY
Last Name:SULLIVAN
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 1:301 COUNTRY CLUB TRAIL
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:17320
Mailing Address - Country:US
Mailing Address - Phone:717-642-6727
Mailing Address - Fax:717-642-4233
Practice Address - Street 1:22 S MARKET STREET
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701
Practice Address - Country:US
Practice Address - Phone:301-682-5683
Practice Address - Fax:301-682-3499
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5094KF60Medicare ID - Type Unspecified
C30050Medicare UPIN