Provider Demographics
NPI:1164756839
Name:SULLIVAN PSYCHIATRIC SVCS LLC
Entity Type:Organization
Organization Name:SULLIVAN PSYCHIATRIC SVCS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-508-3822
Mailing Address - Street 1:425 ALLGOOD RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-6145
Mailing Address - Country:US
Mailing Address - Phone:404-508-3822
Mailing Address - Fax:404-508-3823
Practice Address - Street 1:425 ALLGOOD RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-6145
Practice Address - Country:US
Practice Address - Phone:404-508-3822
Practice Address - Fax:404-508-3823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0471622084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA343324511AMedicaid