Healthcare Provider Details

I. General information

NPI: 1750551834
Provider Name (Legal Business Name): KEVIN L. SULLIVAN MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E PONCE DE LEON AVE
DECATUR GA
30030-3440
US

IV. Provider business mailing address

40 VALLEY STREAM PKWY STE 100
MALVERN PA
19355-1407
US

V. Phone/Fax

Practice location:
  • Phone: 404-377-9171
  • Fax: 404-977-9172
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN L. SULLIVAN
Title or Position: MD
Credential: MD
Phone: 404-377-9171