Provider Demographics
NPI:1881700409
Name:SULLIVAN, MARVIN RANDALL (PT)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:RANDALL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8101
Mailing Address - Country:US
Mailing Address - Phone:813-655-3342
Mailing Address - Fax:813-653-0894
Practice Address - Street 1:116 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8101
Practice Address - Country:US
Practice Address - Phone:813-655-3342
Practice Address - Fax:813-653-0894
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0009849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY908VOtherBLUE CROSS BLUE SHIELD
FLY908VOtherBLUE CROSS BLUE SHIELD