Provider Demographics
NPI:1447276225
Name:SULLIVAN, KEVIN L (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:182 INDUSTRIAL ROAD
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:17327-8626
Mailing Address - Country:US
Mailing Address - Phone:717-235-9352
Mailing Address - Fax:717-235-4024
Practice Address - Street 1:250 PONCE DE LEON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3406
Practice Address - Country:US
Practice Address - Phone:404-377-9171
Practice Address - Fax:404-377-9172
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027085E2085R0202X, 2085R0204X
GA0534302085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA409020411IMedicaid
GA409020411IMedicaid
E71699Medicare UPIN