Provider Demographics
NPI:1306839451
Name:SULLIVAN, MICHAEL W (MD)
Entity Type:Individual
Prefix:DR
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 1:999 S. WASHINGTON AVENUE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601
Mailing Address - Country:US
Mailing Address - Phone:989-790-1001
Mailing Address - Fax:989-790-1002
Practice Address - Street 1:999 S. WASHINGTON AVENUE
Practice Address - Street 2:SUITE #2
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601
Practice Address - Country:US
Practice Address - Phone:989-790-1001
Practice Address - Fax:989-790-1002
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010743242086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4114251Medicaid
MI4114251Medicaid
MIN55110Medicare ID - Type Unspecified