MEDICARE: MARYELLEN SULLIVAN KYLE MD

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	207R00000X	Internal Medicine Physician	32160	SC

General Provider Information

NPI Number	:	1184680928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYELLEN SULLIVAN KYLE MD

Provider Business Mailing Address
First Line	:	PO BOX 751357
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1357
Country	:	US
Telephone Number	:	843-792-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 BEE ST
Second Line	:	SUITE 2100
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5847
Country	:	US
Telephone Number	:	843-792-6500
Fax Number	:	843-792-6511

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

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	10/16/2009

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