Provider Demographics
NPI:1194701615
Name:SULLIVAN, CRAIG D (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-485-4161
Mailing Address - Fax:802-485-4163
Practice Address - Street 1:63 CRESCENT AVE
Practice Address - Street 2:GREEN MOUNTAIN FAMILY PRACTICE
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663-5704
Practice Address - Country:US
Practice Address - Phone:802-485-4161
Practice Address - Fax:802-485-4163
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT042-0007006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005680Medicaid
VTC65599Medicare UPIN
VT0005680Medicaid