Basic Information
| Provider Information | |||||||||
| NPI: | 1780619890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JEREMIAH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 POINT FOSDICK DR NW | ||||||||
| Address2: | STE 202 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538589192 | ||||||||
| FaxNumber: | 2538571489 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 POINT FOSDICK DR NW | ||||||||
| Address2: | STE 202 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983351706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538589192 | ||||||||
| FaxNumber: | 2538571489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00037591 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080144712 | 01 | WA | RAILROAD | OTHER | 0131075 | 01 | WA | STATE L&I | OTHER | 8243149 | 05 | WA | MEDICAID | 8928703 | 01 | WA | STATE CRIME VICTIMS | OTHER |