Provider Demographics
NPI:1649496076
Name:SULLIVAN, MAURICE EUGENE III (DC)
Entity type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:EUGENE
Last Name:SULLIVAN
Suffix:III
Gender:F
Credentials:DC
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 264
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0264
Mailing Address - Country:US
Mailing Address - Phone:217-483-2207
Mailing Address - Fax:217-483-3248
Practice Address - Street 1:1209 N MAIN ST
Practice Address - Street 2:#B
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-0264
Practice Address - Country:US
Practice Address - Phone:217-483-2207
Practice Address - Fax:217-483-3248
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL241020Medicare ID - Type Unspecified
ILU65745Medicare UPIN