Provider Demographics
NPI:1922037548
Name:SULLIVAN, MICHAEL PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
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 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-378-2141
Mailing Address - Fax:360-378-3655
Practice Address - Street 1:1117 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-9782
Practice Address - Country:US
Practice Address - Phone:360-378-2141
Practice Address - Fax:360-378-3655
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033030207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7524SUOtherBSWA
WA8182263Medicaid
WA0168205OtherLIWA
WA0302692OtherL&I AND CRIME VICTIMS
WA7524SUOtherBSWA
WAF62641Medicare UPIN
WAP00308750Medicare PIN