Provider Demographics
NPI:1063508653
Name:SULLIVAN, KAREN E (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:E
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:GA
Mailing Address - Zip Code:30511
Mailing Address - Country:US
Mailing Address - Phone:706-754-9848
Mailing Address - Fax:706-839-1033
Practice Address - Street 1:5126 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:706-754-9848
Practice Address - Fax:706-839-1033
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046259207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22BDDMNMedicare ID - Type Unspecified
GAH99785Medicare UPIN