Provider Demographics
NPI:1689654899
Name:SULLIVAN, MICHAEL ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 13306
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24032-3306
Mailing Address - Country:US
Mailing Address - Phone:540-345-0289
Mailing Address - Fax:540-345-9569
Practice Address - Street 1:5115 BERNARD DR STE 201
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4367
Practice Address - Country:US
Practice Address - Phone:540-345-0289
Practice Address - Fax:540-345-9569
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2020-03-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101238572207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1689654899Medicaid
VA1689654899Medicaid