MEDICARE: MICHAEL PATRICK SULLIVAN 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	2084N0400X	Neurology Physician	G40941	CA
2	2084N0400X	Neurology Physician	6833	NV

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	:	1336105626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL PATRICK SULLIVAN MD

Provider Business Mailing Address
First Line	:	2101 SOUTH AVE
Second Line	:
City	:	SO LAKE TAHOE
State	:	CA
Zip	:	96150
Country	:	US
Telephone Number	:	530-542-5744
Fax Number	:	530-542-5747

Provider Business Practice Location Address
First Line	:	2101 SOUTH AVE
Second Line	:
City	:	SO LAKE TAHOE
State	:	CA
Zip	:	96150
Country	:	US
Telephone Number	:	530-542-5744
Fax Number	:	530-542-5747

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	09/28/2012

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