Active NPI
Kevin Sullivan
- Pediatrics Physician
- Kennesaw, GA
National Provider Identifier
1003497801
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 101921
- Practice address
- 3150 Cobb Pkwy NW Ste 130
Kennesaw, GA 30152-1007 - Phone
- (770) 966-0778
- NPI assigned
- Apr 14, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 101921 | GA | Primary |
Addresses
Primary practice location
3150 Cobb Pkwy NW Ste 130
Kennesaw, GA 30152-1007
Mailing address
3664 Outlook CT NE
Marietta, GA 30066-1788
Phone (678) 478-0853
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MD
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20211001002804 | MD | Order and Referring Only - Pediatric Medicine | 7416355672 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 101921 | GA | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Spectrum Pediatric GRP | Past | Accepting new patients |
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/DAJAAA/Endpoint/DAJAAA
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Medical Specialty Clinic/Center
- Kennesaw, GA
- NPI 1154447043
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1618358400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1740528000000",
"number": "1003497801",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3664 OUTLOOK CT NE",
"city": "MARIETTA",
"state": "GA",
"postal_code": "300661788",
"telephone_number": "678-478-0853"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3150 COBB PKWY NW STE 130",
"city": "KENNESAW",
"state": "GA",
"postal_code": "301521007",
"telephone_number": "770-966-0778"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SULLIVAN",
"first_name": "KEVIN",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-04-14",
"last_updated": "2025-02-26",
"certification_date": "2025-02-26",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "GA",
"license": "101921",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kennesaw, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 26, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.