Provider Demographics
NPI:1629074760
Name:SULLIVAN, CORNELIUS A (MD)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:A
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 1:461 PARK DR
Mailing Address - Street 2:#301
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3825
Mailing Address - Country:US
Mailing Address - Phone:603-502-6070
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY CWN L2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58808207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHE12440Medicare UPIN
NHRE0202Medicare ID - Type Unspecified
MEMM9087Medicare ID - Type Unspecified