Provider Demographics
NPI:1134169220
Name:SULLIVAN, JAMES C (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
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 1:110 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4626
Mailing Address - Country:US
Mailing Address - Phone:877-771-7401
Mailing Address - Fax:401-784-4902
Practice Address - Street 1:909 N MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5752
Practice Address - Country:US
Practice Address - Phone:401-273-4064
Practice Address - Fax:401-273-1268
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7005561Medicaid