Provider Demographics
NPI:1194711804
Name:SULLIVAN, MICHAEL DOUGLAS (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 W ARBORS DR STE 208A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2577
Mailing Address - Country:US
Mailing Address - Phone:704-547-1800
Mailing Address - Fax:704-547-1611
Practice Address - Street 1:2315 W ARBORS DR STE 208A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2577
Practice Address - Country:US
Practice Address - Phone:704-547-1800
Practice Address - Fax:704-547-1611
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0844XOtherBCBS
NC618994OtherACN
NC7998160OtherAETNA-INDIVIDUAL
NC0194LOtherCNC/BCBS-GROUP
NC890844XMedicaid
NC3002130OtherAETNA HMO-SULLIVAN FAMILY
NC7386420OtherAETNA-SULLIVAN FAMILY CHI
NC7386420OtherAETNA-SULLIVAN FAMILY CHI
NC7386420OtherAETNA-SULLIVAN FAMILY CHI
NC2454070AMedicare ID - Type UnspecifiedINDIVIDUAL
NC76-0712972OtherEIN FEDERAL TAX ID