Provider Demographics
NPI:1144221342
Name:SULLIVAN, SHAUN M (PT)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6300
Mailing Address - Country:US
Mailing Address - Phone:989-892-4557
Mailing Address - Fax:989-892-4686
Practice Address - Street 1:2618 CENTER AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6300
Practice Address - Country:US
Practice Address - Phone:989-892-4557
Practice Address - Fax:989-892-4686
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN85020002Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER