Provider Demographics
NPI:1811145758
Name:SULLIVAN MEDICAL, LLC
Entity type:Organization
Organization Name:SULLIVAN MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-830-6667
Mailing Address - Street 1:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5409
Mailing Address - Country:US
Mailing Address - Phone:256-830-6667
Mailing Address - Fax:256-830-5751
Practice Address - Street 1:1874 SLAUGHTER RD STE P
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-5912
Practice Address - Country:US
Practice Address - Phone:256-830-6667
Practice Address - Fax:256-830-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI31636Medicare UPIN