Provider Demographics
NPI:1578685335
Name:SULLIVAN, ANN MARIE THERESA (MD)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:THERESA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HOLLAND AVE
Mailing Address - Street 2:FL 8
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3411
Mailing Address - Country:US
Mailing Address - Phone:518-474-4403
Mailing Address - Fax:
Practice Address - Street 1:80TH ST & 41ST AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-334-3900
Practice Address - Fax:718-334-5958
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1244802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid