Healthcare Provider Details

I. General information

NPI: 1306264890
Provider Name (Legal Business Name): KEVIN MICHAEL SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 PERDIDO ST FL 8
NEW ORLEANS LA
70112-1352
US

IV. Provider business mailing address

2021 PERDIDO ST FL 8
NEW ORLEANS LA
70112-1352
US

V. Phone/Fax

Practice location:
  • Phone: 504-568-4750
  • Fax: 504-568-2202
Mailing address:
  • Phone: 504-568-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number340298
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA171748
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberML60475569
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: