MEDICARE: DR. MICHAEL DOUGLAS SULLIVAN DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2832	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0844X	OTHER	NC	BCBS
2	618994	OTHER	NC	ACN
3	7998160	OTHER	NC	AETNA-INDIVIDUAL
4	0194L	OTHER	NC	CNC/BCBS-GROUP
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	3002130	OTHER	NC	AETNA HMO-SULLIVAN FAMILY
7	7386420	OTHER	NC	AETNA-SULLIVAN FAMILY CHI

General Provider Information

NPI Number	:	1194711804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DOUGLAS SULLIVAN DC

Provider Business Mailing Address
First Line	:	2315 W ARBORS DR STE 208A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-2577
Country	:	US
Telephone Number	:	704-547-1800
Fax Number	:	704-547-1611

Provider Business Practice Location Address
First Line	:	2315 W ARBORS DR STE 208A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-2577
Country	:	US
Telephone Number	:	704-547-1800
Fax Number	:	704-547-1611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	06/29/2021

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