Provider Demographics
NPI:1003984311
Name:SULLIVAN, CHARLES W (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347-1368
Mailing Address - Country:US
Mailing Address - Phone:207-649-2795
Mailing Address - Fax:617-488-2237
Practice Address - Street 1:98 SECOND ST
Practice Address - Street 2:
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347-1368
Practice Address - Country:US
Practice Address - Phone:207-649-2795
Practice Address - Fax:617-488-2237
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1048207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
015555OtherBCBS
ME211750000Medicaid
015219OtherPTAN
ME211750000Medicaid