NPIMap

Individual provider Active NPI

Sullivan Clyde Hanback, MD

  • Emergency Medicine Physician
  • Houston, TX
National Provider Identifier
1417538141
Registry record updated Jun 9, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
U4523 Issued in TX
Practice address
6431 Fannin Street
Suite JJL 270-6
Houston, TX 77030
Phone
(713) 500-7878
Fax
(713) 500-0758
NPI assigned
Apr 15, 2021
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Emergency Medicine Physician 207P00000X U4523 TX Primary

Addresses

Primary practice location

6431 Fannin Street
Suite JJL 270-6
Houston, TX 77030

Mailing address

6431 Fannin Street
Suite JJL 270-6
Houston, TX 77030
Phone (713) 500-7878

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA, TX2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20240322000301 PA Practitioner - Emergency Medicine 0941647259 Reassigns benefits to 1 organization
I20260508000353 TX Practitioner - Emergency Medicine 0941647259 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
University of Alabama School of Medicine, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Temple Faculty Practice Plan IncGroup PAC ID 0345588711, 1,325 clinicians

Practice addresses (Care Compare)

3401 N Broad St
Philadelphia, PA 19140-5103
Phone (215) 707-3008

Hospital & facility affiliations

  • Temple University Hospital Hospital, Philadelphia, PA, CCN 390027

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
U4523TXMDEmergency Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Temple Faculty Practice Plan Inc CurrentSince Feb 10, 2024 Accepting new patients
Temple Faculty Practice Plan Inc Current Accepting new patients
Temple Faculty Practice Plan, Inc Emergency Medicine CurrentSince Feb 10, 2024 Accepting new patients

Locations

3401 N Broad St
Philadelphia, PA 19140
Phone (215) 707-3807

3500 N Broad St
Philadelphia, PA 19140
Phone (215) 707-3656

100 E Lehigh Ave
Philadelphia, PA 19125
Phone (215) 707-1200

Organizations & group practices 4

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.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1618444800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1780963200000",
    "number": "1417538141",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6431 FANNIN STREET",
            "address_2": "SUITE JJL 270-6",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "77030",
            "telephone_number": "713-500-7878",
            "fax_number": "713-500-0758"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6431 FANNIN STREET",
            "address_2": "SUITE JJL 270-6",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "77030",
            "telephone_number": "713-500-7878",
            "fax_number": "713-500-0758"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HANBACK",
        "first_name": "SULLIVAN",
        "middle_name": "CLYDE",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-04-15",
        "last_updated": "2026-06-09",
        "certification_date": "2026-06-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "TX",
            "license": "U4523",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Houston, TX

Sources for this page

Verify at the official NPI Registry.