Provider Demographics
NPI:1245208883
Name:SULLIVAN, EUGENE DENIS (PA-C)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:DENIS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-8938
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-8938
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN86630022Medicare ID - Type UnspecifiedPEC OKW
MIN87450007Medicare ID - Type UnspecifiedOKW SJMM
P40010024Medicare PIN
MIQ24594206Medicare ID - Type UnspecifiedMHP OKW-SJMM
P40540025Medicare PIN
MIP83095Medicare UPIN