Provider Demographics
NPI:1639406283
Name:SULLIVAN, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5842
Mailing Address - Country:US
Mailing Address - Phone:401-633-2690
Mailing Address - Fax:
Practice Address - Street 1:65 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5842
Practice Address - Country:US
Practice Address - Phone:401-633-2690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist