Provider Demographics
NPI:1689949331
Name:SULLIVAN, RYAN JAMES
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
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 1:3536 MERIDIAN CROSSINGS
Mailing Address - Street 2:SUITE 240
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4584
Mailing Address - Country:US
Mailing Address - Phone:517-347-2495
Mailing Address - Fax:517-347-3540
Practice Address - Street 1:3536 MERIDIAN CROSSINGS
Practice Address - Street 2:SUITE 240
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4584
Practice Address - Country:US
Practice Address - Phone:517-347-2495
Practice Address - Fax:517-347-3540
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist