Basic Information
| Provider Information | |||||||||
| NPI: | 1689654899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13306 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240323306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403450289 | ||||||||
| FaxNumber: | 5403459569 | ||||||||
| Practice Location | |||||||||
| Address1: | 5115 BERNARD DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240184367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403450289 | ||||||||
| FaxNumber: | 5403459569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0101238572 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1689654899 | 05 | WV | MEDICAID | 1689654899 | 05 | VA | MEDICAID |