Healthcare Provider Details

I. General information

NPI: 1134309198
Provider Name (Legal Business Name): KELLY SULLIVAN,M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 BESTGATE RD SUITE 208
ANNAPOLIS MD
21401-3091
US

IV. Provider business mailing address

888 BESTGATE RD SUITE 208
ANNAPOLIS MD
21401-3091
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-1280
  • Fax: 410-571-1288
Mailing address:
  • Phone: 410-571-1280
  • Fax: 410-571-1288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY M SULLIVAN
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 410-571-1280