Provider Demographics
NPI:1659334597
Name:SULLIVAN, GARY B (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:SULLIVAN
Suffix:
Gender:M
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:PO BOX 1958
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1958
Mailing Address - Country:US
Mailing Address - Phone:912-871-2000
Mailing Address - Fax:912-871-2500
Practice Address - Street 1:1523 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-6025
Practice Address - Country:US
Practice Address - Phone:912-871-2000
Practice Address - Fax:912-871-2500
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30224174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000353955CMedicaid
GAD41196Medicare UPIN
GA16BDGCHMedicare ID - Type Unspecified