Provider Demographics
NPI:1346534484
Name:SULLIVAN, ROGER PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:PATRICK
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 1:9228 MEDICAL PLAZA DR
Mailing Address - Street 2:DEPT FAMILY MEDICINE
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9125
Mailing Address - Country:US
Mailing Address - Phone:843-876-7080
Mailing Address - Fax:
Practice Address - Street 1:9228 MEDICAL PLAZA DR
Practice Address - Street 2:DEPT FAMILY MEDICINE
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9125
Practice Address - Country:US
Practice Address - Phone:843-876-7080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL33609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine