Provider Demographics
NPI:1538143904
Name:SULLIVAN, CHRISTOPHER ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ALBERT
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-9440
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-9440
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500610207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
805849OtherPARTNERS
VA10157978Medicaid
182602OtherMEDCOST
WV3810001904Medicaid
139F4OtherBCBS
7184757OtherAETNA
P00404443OtherRR MEDICARE
NC5900684Medicaid
NC5900684Medicaid
NC2039859Medicare PIN