MEDICARE: BRIAN L SULLIVAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	E1946	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053395079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN L SULLIVAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 52194
Second Line	:	DEPARTMENT 959
City	:	PHOENIX
State	:	AZ
Zip	:	85072-2194
Country	:	US
Telephone Number	:	512-451-1969
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W WILLIAM CANNON DR
Second Line	:	STE 401
City	:	AUSTIN
State	:	TX
Zip	:	78745-5257
Country	:	US
Telephone Number	:	512-451-1969
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	10/25/2010

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