Provider Demographics
NPI:1518953710
Name:SULLIVAN, JOSEPH BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BRIAN
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 1:82 BEACH ST
Mailing Address - Street 2:PO BOX 923
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093-1560
Mailing Address - Country:US
Mailing Address - Phone:508-384-8748
Mailing Address - Fax:
Practice Address - Street 1:620 WASHINGTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-3300
Practice Address - Country:US
Practice Address - Phone:508-553-9145
Practice Address - Fax:508-520-3167
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3079066Medicaid
MAE85584Medicare UPIN
MA3079066Medicaid