Provider Demographics
NPI:1265495659
Name:SULLIVAN, MICHAEL STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STANLEY
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:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-636-1919
Mailing Address - Fax:252-636-2656
Practice Address - Street 1:2636 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4238
Practice Address - Country:US
Practice Address - Phone:252-636-1919
Practice Address - Fax:252-636-2656
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-01788208000000X
RIMD09704208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN