Basic Information
| Provider Information | |||||||||
| NPI: | 1922037548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5096 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982275096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603782141 | ||||||||
| FaxNumber: | 3603783655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | FRIDAY HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982509782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603782141 | ||||||||
| FaxNumber: | 3603783655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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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 | 207P00000X | MD00033030 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7524SU | 01 | WA | BSWA | OTHER | 8182263 | 05 | WA | MEDICAID | 0168205 | 01 | WA | LIWA | OTHER | 0302692 | 01 | WA | L&I AND CRIME VICTIMS | OTHER |