Provider Demographics
NPI:1780683151
Name:SULLIVAN, MACK HUGH JR (MD)
Entity Type:Individual
Prefix:MR
First Name:MACK
Middle Name:HUGH
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:44199 DEQUINDRE RD.
Mailing Address - Street 2:SUITE 518
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085
Mailing Address - Country:US
Mailing Address - Phone:248-524-0640
Mailing Address - Fax:248-994-0866
Practice Address - Street 1:44199 DEQUINDRE RD.
Practice Address - Street 2:SUITE 518
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085
Practice Address - Country:US
Practice Address - Phone:248-524-0640
Practice Address - Fax:248-994-0866
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2013-01-15
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Provider Licenses
StateLicense IDTaxonomies
MI4301094101208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG30816Medicare UPIN
G30816Medicare UPIN