Provider Demographics
NPI:1750609004
Name:SULLIVAN, MATTHEW PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
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 1:6620 FLY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9791
Mailing Address - Country:US
Mailing Address - Phone:315-464-4472
Mailing Address - Fax:
Practice Address - Street 1:6620 FLY RD
Practice Address - Street 2:STE 200
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9791
Practice Address - Country:US
Practice Address - Phone:315-464-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60545599207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04488400Medicaid
NYJ400320491Medicare PIN