Provider Demographics
NPI:1083714042
Name:JAMES S SULLIVAN M.D. PA
Entity Type:Organization
Organization Name:JAMES S SULLIVAN M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-1038
Mailing Address - Street 1:4300 MAIN ST W
Mailing Address - Street 2:SUITE 16
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1098
Mailing Address - Country:US
Mailing Address - Phone:334-793-1038
Mailing Address - Fax:334-615-8444
Practice Address - Street 1:4300 MAIN ST W
Practice Address - Street 2:SUITE 16
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1098
Practice Address - Country:US
Practice Address - Phone:334-793-1038
Practice Address - Fax:334-615-8444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5184207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000010568Medicaid
AL000010568Medicaid
AL000010568Medicare ID - Type Unspecified