Provider Demographics
NPI:1952303463
Name:SULLIVAN, KEVIN P (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 SPEEN ST
Mailing Address - Street 2:ORTHOPEDICS NEW ENGLAND
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1538
Mailing Address - Country:US
Mailing Address - Phone:508-655-0471
Mailing Address - Fax:508-650-3547
Practice Address - Street 1:313 SPEEN ST
Practice Address - Street 2:ORTHOPEDICS NEW ENGLAND
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1538
Practice Address - Country:US
Practice Address - Phone:508-655-0471
Practice Address - Fax:508-650-3547
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA156166208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0146447Medicaid
MAH43832Medicare UPIN
MAH43832Medicare UPIN