Provider Demographics
NPI:1619929635
Name:SULLIVAN, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2360 MULLAN RD
Mailing Address - Street 2:SUITE C.
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-721-4436
Mailing Address - Fax:406-721-6053
Practice Address - Street 1:2360 MULLAN RD
Practice Address - Street 2:SUITE C.
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-721-4436
Practice Address - Fax:406-721-6053
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT12035207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery