MEDICARE: DR. SUZANNE R 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	207L00000X	Anesthesiology Physician	09191	MS

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	:	1760598569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUZANNE R SULLIVAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 321360
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-1360
Country	:	US
Telephone Number	:	601-936-0681
Fax Number	:	601-936-0686

Provider Business Practice Location Address
First Line	:	1026 N FLOWOOD DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9532
Country	:	US
Telephone Number	:	601-932-1000
Fax Number	:

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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