Healthcare Provider Details

I. General information

NPI: 1376832667
Provider Name (Legal Business Name): HAROLD CLIFFORD SULLIVAN III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE ROOM H183
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1364 CLIFTON RD NE ROOM H183
ATLANTA GA
30322-1059
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-5947
  • Fax:
Mailing address:
  • Phone: 404-712-5947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number72929
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number72929
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: