Provider Demographics
NPI:1972761252
Name:SULLIVAN, BRIAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
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 1:514 AMERICAS WAY
Mailing Address - Street 2:APT 6347
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719-7600
Mailing Address - Country:US
Mailing Address - Phone:949-444-6695
Mailing Address - Fax:
Practice Address - Street 1:202 S 4TH ST W
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:MT
Practice Address - Zip Code:59313-9156
Practice Address - Country:US
Practice Address - Phone:406-778-2833
Practice Address - Fax:406-778-5355
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT49845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine