Healthcare Provider Details

I. General information

NPI: 1023236494
Provider Name (Legal Business Name): RACHEL AILEEN SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PLAIN ST STE 203
PROVIDENCE RI
02905-3241
US

IV. Provider business mailing address

235 PLAIN ST STE 203
PROVIDENCE RI
02905-3241
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4901
  • Fax: 401-649-4903
Mailing address:
  • Phone: 401-649-4901
  • Fax: 401-649-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD13340
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number245997
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD0069074
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: