MEDICARE: DR. HURSIE J DAVIS-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	207Q00000X	Family Medicine Physician	13888	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CG6643	OTHER	MS	RR MEDICARE HFCA 33
2	080153132	OTHER	MS	RR MEDICARE HFCA 31

Other Identifiers

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

General Provider Information

NPI Number	:	1912104159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HURSIE J DAVIS-SULLIVAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 55869
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39296-5869
Country	:	US
Telephone Number	:	601-373-2940
Fax Number	:	601-373-2720

Provider Business Practice Location Address
First Line	:	1814 HOSPITAL DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39204-3410
Country	:	US
Telephone Number	:	601-373-2940
Fax Number	:	601-373-2720

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

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	07/11/2013

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Directions to “ DR. HURSIE J DAVIS-SULLIVAN M.D.” Practice Location

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