Provider Demographics
NPI:1447570288
Name:SULLIVAN, PATRICK B (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:B
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 1:125 WHIPPLE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3258
Mailing Address - Country:US
Mailing Address - Phone:401-854-2504
Mailing Address - Fax:401-427-7795
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2894
Practice Address - Country:US
Practice Address - Phone:401-793-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14523207P00000X
MA282126207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099845AMedicaid