Healthcare Provider Details

I. General information

NPI: 1578208039
Provider Name (Legal Business Name): COURTNEY SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-0100
US

IV. Provider business mailing address

171 ASHLEY AVE
CHARLESTON SC
29425-0100
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: