Provider Demographics
NPI:1659351070
Name:SULLIVAN, MICHELLE L (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 N LA GRANGE RD # 365
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2008
Mailing Address - Country:US
Mailing Address - Phone:877-905-0336
Mailing Address - Fax:877-905-0336
Practice Address - Street 1:18210 LA GRANGE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-7722
Practice Address - Country:US
Practice Address - Phone:708-478-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G26718Medicare UPIN