Provider Demographics
NPI:1134309198
Name:KELLY SULLIVAN,M.D.,P.C.
Entity Type:Organization
Organization Name:KELLY SULLIVAN,M.D.,P.C.
Other - Org Name:PLASTIC & RECONSTRUCTIVE SURGERY OF ANNAPOLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-571-1280
Mailing Address - Street 1:888 BESTGATE RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3091
Mailing Address - Country:US
Mailing Address - Phone:410-571-1280
Mailing Address - Fax:410-571-1288
Practice Address - Street 1:888 BESTGATE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3091
Practice Address - Country:US
Practice Address - Phone:410-571-1280
Practice Address - Fax:410-571-1288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD641MMedicare PIN