Provider Demographics
NPI:1841201118
Name:SULLIVAN, MARY P (DO)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 HAND AVE
Mailing Address - Street 2:
Mailing Address - City:BAY MINETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36507-4110
Mailing Address - Country:US
Mailing Address - Phone:251-937-5521
Mailing Address - Fax:
Practice Address - Street 1:1815 HAND AVE
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-4110
Practice Address - Country:US
Practice Address - Phone:251-580-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO832207P00000X
ALDO832207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051000772OtherBLUE CROSS&BLUE SHIELD