Provider Demographics
NPI:1275576944
Name:SULLIVAN, MICHAEL W (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
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 1:1600 SPEARHEAD DIVISION AVE DEPT 140
Mailing Address - Street 2:
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40122-5104
Mailing Address - Country:US
Mailing Address - Phone:502-613-4605
Mailing Address - Fax:502-613-4549
Practice Address - Street 1:1600 SPEARHEAD DIVISION AVE DEPT 140
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40122-5104
Practice Address - Country:US
Practice Address - Phone:502-613-4605
Practice Address - Fax:502-613-4549
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20770207Q00000X
WI37645020207V00000X
KY30828208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47600743623Medicaid
NE47600743612Medicaid
NE47600743621Medicaid
NE47600743622Medicaid
NE47600743622Medicaid