Provider Demographics
NPI:1417059338
Name:SULLIVAN, JAMES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
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 1:9 CAREY ROAD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-480-0108
Practice Address - Street 1:3767 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1837
Practice Address - Country:US
Practice Address - Phone:518-623-2844
Practice Address - Fax:518-623-3416
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D72342Medicare UPIN
56464EMedicare ID - Type Unspecified