Healthcare Provider Details

I. General information

NPI: 1316943863
Provider Name (Legal Business Name): MICHAEL W SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 MAIN ST FL 2
SNYDER NY
14226-3800
US

IV. Provider business mailing address

4510 MAIN ST FL 2
SNYDER NY
14226-3800
US

V. Phone/Fax

Practice location:
  • Phone: 716-839-3057
  • Fax: 716-839-1477
Mailing address:
  • Phone: 716-839-3057
  • Fax: 716-839-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number206629
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: