Provider Demographics
NPI:1639761760
Name:SULLIVAN, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
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 1:420 RACE ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-5574
Mailing Address - Country:US
Mailing Address - Phone:413-334-8897
Mailing Address - Fax:
Practice Address - Street 1:208 RACE ST # 16
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5724
Practice Address - Country:US
Practice Address - Phone:413-315-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor