Basic Information
| Provider Information | |||||||||
| NPI: | 1730107913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SULLIVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1365C CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047784446 | ||||||||
| FaxNumber: | 4047784747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1365C CLIFTON RD NE | ||||||||
| Address2: | SUITE C1104 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047784446 | ||||||||
| FaxNumber: | 4047784747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 050543 | GA | N | Other Service Providers | Specialist | 2085R0202X | 50543 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 050543 | 01 | GA | GA. MED. LICENSE | OTHER |