Provider Demographics
NPI:1336282961
Name:SULLIVAN, BRIAN C (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
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 1:653 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1554
Mailing Address - Country:US
Mailing Address - Phone:617-464-0900
Mailing Address - Fax:617-464-3434
Practice Address - Street 1:653 E BROADWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1554
Practice Address - Country:US
Practice Address - Phone:617-464-0900
Practice Address - Fax:617-464-3434
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACHI2069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45503Medicare ID - Type Unspecified