Healthcare Provider Details

I. General information

NPI: 1841619764
Provider Name (Legal Business Name): COLIN A SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SIMMONS LOOP
RIVERVIEW FL
33578-9498
US

IV. Provider business mailing address

2502 W SAINT ISABEL ST STE B
TAMPA FL
33607-6355
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-8000
  • Fax: 813-874-5908
Mailing address:
  • Phone: 813-874-5707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME130061
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: