Provider Demographics
NPI:1881616068
Name:SULLIVAN, MACK LEE (MD)
Entity type:Individual
Prefix:
First Name:MACK
Middle Name:LEE
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 1:369 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:EASTCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10709-2805
Mailing Address - Country:US
Mailing Address - Phone:914-395-3691
Mailing Address - Fax:914-395-3693
Practice Address - Street 1:150 LAKE AVE
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-3306
Practice Address - Country:US
Practice Address - Phone:914-395-3691
Practice Address - Fax:914-395-3693
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203477-1207P00000X
NY203477208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5C5609OtherHEALTHNET
NY5C5609OtherHEALTHNET