Provider Demographics
NPI:1184680928
Name:KYLE, MARYELLEN SULLIVAN (MD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:SULLIVAN
Last Name:KYLE
Suffix:
Gender:F
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:PO BOX 751357
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1357
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:30 BEE ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5847
Practice Address - Country:US
Practice Address - Phone:843-792-6500
Practice Address - Fax:843-792-6511
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32160207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C34189Medicare UPIN