Provider Demographics
NPI:1164531042
Name:SULLIVAN, MICHAEL WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:16700 21 MILE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4887
Mailing Address - Country:US
Mailing Address - Phone:586-263-0320
Mailing Address - Fax:586-263-1276
Practice Address - Street 1:16700 21 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4887
Practice Address - Country:US
Practice Address - Phone:586-263-0320
Practice Address - Fax:586-263-1276
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0855010004OtherBCBSM
MI2109780 11Medicare ID - Type Unspecified
MI0855010004OtherBCBSM
MI85000206011Medicare ID - Type Unspecified