Provider Demographics
NPI:1588822415
Name:SULLIVAN, MEG SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:MEG
Middle Name:SHANNON
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 1:211 W 21ST ST
Mailing Address - Street 2:#2R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-3129
Mailing Address - Country:US
Mailing Address - Phone:646-319-8602
Mailing Address - Fax:
Practice Address - Street 1:211 WEST 21ST STREET
Practice Address - Street 2:#2R
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:636-319-8602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics