Provider Demographics
NPI:1386004638
Name:KENT N SULLIVAN MD PLLC
Entity Type:Organization
Organization Name:KENT N SULLIVAN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:N
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-406-5723
Mailing Address - Street 1:19219 51ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-2940
Mailing Address - Country:US
Mailing Address - Phone:206-406-5723
Mailing Address - Fax:206-527-0147
Practice Address - Street 1:19219 51ST AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-2940
Practice Address - Country:US
Practice Address - Phone:206-406-5723
Practice Address - Fax:206-527-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0001591207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA05736Medicare UPIN