Provider Demographics
NPI:1821069923
Name:SULLIVAN, CHARLES CURTIS (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CURTIS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:120 MEDICAL BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-0220
Mailing Address - Country:US
Mailing Address - Phone:352-688-2118
Mailing Address - Fax:352-688-3118
Practice Address - Street 1:120 MEDICAL BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0220
Practice Address - Country:US
Practice Address - Phone:352-688-2118
Practice Address - Fax:352-688-3118
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BCBS37656OtherBCBS
FIRST HEALTH 2160822OtherFIRST HEALTH
FLI02577Medicare UPIN
FL37656ZMedicare ID - Type Unspecified