Provider Demographics
NPI:1881696003
Name:SULLIVAN, RYAN J (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
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 1:330 MT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5502
Mailing Address - Country:US
Mailing Address - Phone:617-499-5112
Mailing Address - Fax:617-575-8608
Practice Address - Street 1:330 MT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5502
Practice Address - Country:US
Practice Address - Phone:617-499-5112
Practice Address - Fax:617-575-8608
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2097702Medicaid
MA2097702Medicaid
MAA38111Medicare ID - Type Unspecified