Provider Demographics
NPI:1669476388
Name:SULLIVAN, BETH ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:CORNISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1960 RIVERSIDE PKWY
Mailing Address - Street 2:STE 106
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5945
Mailing Address - Country:US
Mailing Address - Phone:678-407-2222
Mailing Address - Fax:
Practice Address - Street 1:1960 RIVERSIDE PKWY
Practice Address - Street 2:STE 106
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5945
Practice Address - Country:US
Practice Address - Phone:678-407-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049106207Q00000X, 208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7393382OtherAETNA PROVIDER ID
GA10041812Medicaid
GA54305OtherSOUTHCARE ID
GA000888698DMedicaid
GA327120Medicaid
GA85002412GMedicaid
GA903825OtherBCBSGA PROVIDER ID
GA08BBRCPMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
GA000888698DMedicaid
GA85002412GMedicaid