Healthcare Provider Details

I. General information

NPI: 1447276225
Provider Name (Legal Business Name): KEVIN L. SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PONCE DE LEON AVE SUITE 100
DECATUR GA
30030-3406
US

IV. Provider business mailing address

182 INDUSTRIAL ROAD
GLEN ROCK PA
17327-8626
US

V. Phone/Fax

Practice location:
  • Phone: 404-377-9171
  • Fax: 404-377-9172
Mailing address:
  • Phone: 717-235-9352
  • Fax: 717-235-4024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD027085E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD027085E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number053430
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: