Healthcare Provider Details

I. General information

NPI: 1972761252
Provider Name (Legal Business Name): BRIAN MICHAEL SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S 4TH ST W
BAKER MT
59313-9156
US

IV. Provider business mailing address

514 AMERICAS WAY APT 6347
BOX ELDER SD
57719-7600
US

V. Phone/Fax

Practice location:
  • Phone: 406-778-2833
  • Fax: 406-778-5355
Mailing address:
  • Phone: 949-444-6695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49845
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: