Provider Demographics
NPI:1881074896
Name:SULLIVAN, MICHAEL GREGORY (RN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HOBOMACK RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-2508
Mailing Address - Country:US
Mailing Address - Phone:617-773-7329
Mailing Address - Fax:
Practice Address - Street 1:30 HOBOMACK RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-2508
Practice Address - Country:US
Practice Address - Phone:617-773-7329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2284306315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid