Provider Demographics
NPI:1629165063
Name:RYAN A SULLIVAN, MD PC
Entity Type:Organization
Organization Name:RYAN A SULLIVAN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-398-1850
Mailing Address - Street 1:1391 E PARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9352
Mailing Address - Country:US
Mailing Address - Phone:231-398-1850
Mailing Address - Fax:
Practice Address - Street 1:1391 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9352
Practice Address - Country:US
Practice Address - Phone:231-398-1850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDE0302OtherRAILROAD MEDICARE
MIP00267590OtherRAILROAD MEDICARE
MI0511518OtherBCBS