Healthcare Provider Details

I. General information

NPI: 1184086456
Provider Name (Legal Business Name): CHRISTOPHER THOMAS SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 S STATE ST
ELGIN IL
60123-7692
US

IV. Provider business mailing address

750 S STATE ST GOLDMAN BUILDING, BRUNK UNIT
ELGIN IL
60123-7612
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-1040
  • Fax:
Mailing address:
  • Phone: 847-742-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.151666
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: