Healthcare Provider Details

I. General information

NPI: 1154412906
Provider Name (Legal Business Name): STEPHEN R SULLIVAN M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/10/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MOUNT AUBURN ST STE 304
CAMBRIDGE MA
02138-5665
US

IV. Provider business mailing address

300 MOUNT AUBURN STREET SUITE 304
CAMBRIDGE MA
02138
US

V. Phone/Fax

Practice location:
  • Phone: 617-492-0620
  • Fax: 617-492-0631
Mailing address:
  • Phone: 617-492-0620
  • Fax: 617-492-0631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number233018
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: