Provider Demographics
NPI:1912104159
Name:DAVIS-SULLIVAN, HURSIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:HURSIE
Middle Name:J
Last Name:DAVIS-SULLIVAN
Suffix:
Gender:F
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:PO BOX 55869
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-5869
Mailing Address - Country:US
Mailing Address - Phone:601-373-2940
Mailing Address - Fax:601-373-2720
Practice Address - Street 1:1814 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3410
Practice Address - Country:US
Practice Address - Phone:601-373-2940
Practice Address - Fax:601-373-2720
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCG6643OtherRR MEDICARE HFCA 33
MS080153132OtherRR MEDICARE HFCA 31
MS08236531Medicaid
MS00112110Medicaid
MS640918786OtherEIN
MS08236531Medicaid
MSC02914Medicare ID - Type UnspecifiedHCFA 33
MS00112110Medicaid