Basic Information
| Provider Information | |||||||||
| NPI: | 1811145758 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SULLIVAN MEDICAL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MADISON PRIMARY CARE AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1768 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357585409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568306667 | ||||||||
| FaxNumber: | 2568305751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1874 SLAUGHTER RD STE P | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357585912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568306667 | ||||||||
| FaxNumber: | 2568305751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2568306667 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO832 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.