Provider Demographics
NPI:1639161912
Name:SULLIVAN, MICHAEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1535 E. BROOMFIELD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MT. PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-772-3339
Mailing Address - Fax:989-772-4846
Practice Address - Street 1:1535 E. BROOMFIELD
Practice Address - Street 2:SUITE A
Practice Address - City:MT. PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-772-3339
Practice Address - Fax:989-772-4846
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2011-07-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIMS039558207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMS039558OtherSTATE LICENSE NUMBER
MI1625778Medicaid
MIMS039558OtherSTATE LICENSE NUMBER
MIA77140Medicare UPIN