Provider Demographics
NPI:1790830792
Name:SULLIVAN, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
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 177
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-0177
Mailing Address - Country:US
Mailing Address - Phone:307-789-3464
Mailing Address - Fax:307-789-7373
Practice Address - Street 1:831 STATE HIGHWAY 150 S
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5340
Practice Address - Country:US
Practice Address - Phone:307-789-3464
Practice Address - Fax:307-789-7373
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5348A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1790830792OtherNATIONAL PROVIDER IDENTIFICATION
WYB65928Medicare UPIN