Basic Information
| Provider Information | |||||||||
| NPI: | 1609931781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EMMETT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622351000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 N CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | ADAIRSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301032467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4706015650 | ||||||||
| FaxNumber: | 7708773655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042742 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 925256491A | 05 | GA | MEDICAID | 925256491B | 05 | GA | MEDICAID |