Provider Demographics
NPI:1164713756
Name:SULLIVAN, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 1:2700 WAYNE MEMORIAL DR
Mailing Address - Street 2:MEDICAL EDUCATION
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 WAYNE MEMORIAL DR
Practice Address - Street 2:MEDICAL EDUCATION
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9494
Practice Address - Country:US
Practice Address - Phone:919-736-1110
Practice Address - Fax:315-624-6469
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276980208M00000X
NC2016-00449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03914734Medicaid
NYJ400169399Medicare UPIN