Provider Demographics
NPI:1750551834
Name:KEVIN L. SULLIVAN MD, PC
Entity type:Organization
Organization Name:KEVIN L. SULLIVAN MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-377-9171
Mailing Address - Street 1:40 VALLEY STREAM PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:484-924-0053
Practice Address - Street 1:250 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3440
Practice Address - Country:US
Practice Address - Phone:404-377-9171
Practice Address - Fax:404-977-9172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty