Basic Information
| Provider Information | |||||||||
| NPI: | 1578685335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | ANN MARIE | ||||||||
| MiddleName: | THERESA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 HOLLAND AVE | ||||||||
| Address2: | FL 8 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184744403 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80TH ST & 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343900 | ||||||||
| FaxNumber: | 7183345958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 124480 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00246075 | 05 | NY | MEDICAID |