Provider Demographics
NPI:1538368923
Name:SULLIVAN, ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2454
Practice Address - Street 1:2145 HENRY TECKLENBURG DR 220
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-2963
Practice Address - Country:US
Practice Address - Phone:843-723-8823
Practice Address - Fax:843-606-8059
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19223207L00000X
NC2008-01579207L00000X, 207LP2900X, 208VP0014X
SC32237207L00000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911895Medicaid
SCNC1040Medicaid
SCP01163110OtherRAILROAD-MEDICARE
NCP01011085OtherRAILROAD-MEDICARE
NC152J3OtherBCBSNC
NCP01011085OtherRAILROAD-MEDICARE
SCP01163110OtherRAILROAD-MEDICARE