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General NPI Number Information
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NPI Number | 1003497801
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Entity Type | Individual
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Provider Name | KEVIN SULLIVAN
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Gender | Male
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Dates
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Enumeration Date | 04/14/2021
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Last Update Date | 02/26/2025
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Provider Practice Location Address
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Address Line | 3150 COBB PKWY NW STE 130
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City | KENNESAW
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State | GA
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Zip | 30152-1007
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Country | US
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Telephone | 770-966-0778
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Fax |
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Provider Business Mailing Address
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Address Line | 3664 OUTLOOK CT NE
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City | MARIETTA
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State | GA
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Zip | 30066-1788
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Country | US
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Telephone | 678-478-0853
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 101921
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License Number State | GA
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