Provider Demographics
NPI:1336282961
Name:SULLIVAN, BRIAN C (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 RANTOUL ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4241
Mailing Address - Country:US
Mailing Address - Phone:978-921-4440
Mailing Address - Fax:978-921-6349
Practice Address - Street 1:142 RANTOUL ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4241
Practice Address - Country:US
Practice Address - Phone:978-921-4440
Practice Address - Fax:978-921-6349
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAX2069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45503Medicare ID - Type Unspecified