Healthcare Provider Details

I. General information

NPI: 1194701615
Provider Name (Legal Business Name): CRAIG D SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CRESCENT AVE GREEN MOUNTAIN FAMILY PRACTICE
NORTHFIELD VT
05663-5704
US

IV. Provider business mailing address

PO BOX 547 CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-485-4161
  • Fax: 802-485-4163
Mailing address:
  • Phone: 802-485-4161
  • Fax: 802-485-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-0007006
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: