Provider Demographics
NPI:1649453903
Name:SULLIVAN, C EUGENE (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:EUGENE
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 2066
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-2066
Mailing Address - Country:US
Mailing Address - Phone:208-344-9424
Mailing Address - Fax:208-344-3263
Practice Address - Street 1:210 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6044
Practice Address - Country:US
Practice Address - Phone:208-344-9424
Practice Address - Fax:208-343-3263
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0024588Medicaid
IDE08600Medicare UPIN