Provider Demographics
NPI:1174605653
Name:SULLIVAN, RYAN A (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-8632
Mailing Address - Country:US
Mailing Address - Phone:231-882-9661
Mailing Address - Fax:231-882-9616
Practice Address - Street 1:2198 US HIGHWAY 31 S
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9618
Practice Address - Country:US
Practice Address - Phone:231-723-3567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430308010207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00267590OtherRAILROAD MEDICARE
MI4764828Medicaid
MI1105115182OtherBCBS
MI4764828Medicaid
MI0P21490001Medicare ID - Type UnspecifiedMEDICARE